Give In Honor
The deadline to receive all artwork and completed applications has been extended to July 15, 2019.
Title of Artwork
Please provide a short description of the artwork.
Artist First Name
Artist Last Name
Gender Male Female
Please upload a recent close-up photo of the artist
Dialysis/Medical Facility Name
Dialysis/Medical Facility Phone Number
Dialysis/Medical Facility Contact Name and Title
Dialysis/Medical Facility Email Address
Dialysis/Medical Facility Address
Dialysis/Medical Facility City
Dialysis/Medical Facility State
Dialysis/Medical Facility Zip
Artist is Currently Kidney Disease Patient Hemodialysis Patient Peritoneal Dialysis Patient Transplant Patient Other
If Artist is a Kidney Disease Patient or Other as noted above, what type?
Dialysis InformationIf on dialysis, please indicate your child's usual treatment days. Monday Tuesday Wednesday Thursday Friday Saturday Sunday Not Applicable
School Information Attend school regularly Homeschool Work with a local school, but study at home Other
Answer the questions below with as much information as you can.
Where did you get the idea for your art?
What made you decide to enter the calendar contest?
What hobbies do you have?
Who is your role model and why?
FOR KIDS 12 AND OLDER: What are your plans after high school? (college, career, etc.)
FOR KIDS UNDER 12: What do you want to be when you grown up?
How is your day-to-day life affected by kidney disease?
What advice would you give to other kids with kidney disease?
How has a friend, family or celebrity inspired you to deal with your disease?
What type of artwork is being submitted? Drawing or Painting Song Performance Dance Performance Short Film Poem or Short Story
Please select one of the two options below to provide a file or a link to the artists work.
Upload a picture of your drawing, painting, poem or short story.
If you uploaded your video or film to YouTube, please share the link.
Signature is required by parent/legal guardian I/we am/are the custodial parent(s) and/or legal guardian of the child submitting this artwork, hereinafter "my/our" child.
In consideration of participation in the Events and/or Activities, I/we grant to the American Kidney Fund full rights to take pictures, photographs, and/or video (including recordings) of my/our child in connection with the Events and/or Activities, and to make use of such pictures, photographs and/or videos as the American Kidney Fund shall deem appropriate. I/we understand that the copyright to all such pictures, photographs and/or video shall be and remain the exclusive property of the American Kidney Fund. Further, I/we grant permission to the American Kidney Fund, without limitation, the right to collect and use information about my/our child.
I/we further grant and assign to the American Kidney Fund the exclusive copyright and all otehr property rights in and to the art created by my/our child in order that the American Kidney fund may make sure of it in the calendar it will publish and in such other publications as the American Kidney Fund shall deep appropriate in the exercise of its sole discretion. I/we understand that no payment, royalty, or other consideration will be paid by the American Kidney Fund in return for the copyright to the art which is an absolute and unconditional gift to the American Kidney Fund.
Parent or Legal Guardian
Signature Date (MM/DD/YYYY)
Parent or Legal Guardian 2
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