APPENDIX 3

Consent to Photograph, Record, Video Students and Publish, Display, Distribute or Broadcast Students’ Image and or Work

During the course of the school year, students at _______________________ School are occasionally videotaped, recorded, and or photographed for a variety of reasons, including school awards, special recognition, yearbooks, video projects and news programming. The student’s name, school and grade may accompany such photographs, videos and web pages.

Some of these photographs / video images are published, displayed, distributed or broadcast outside of the school network and in these cases the School Board is required to obtain consent.

Please fill in the requested information and check either Yes or No below to indicate whether you wish to give or not give consent.

Student Name___________________________

School__________________________________

Grade ________Room ________Teacher ______________________________

I hereby release the school and the School Board from any liability or damages resulting from or connected with the publication of such work: Yes________ No________

 

Signature __________________________ Date _______________________

Parent/ Guardian / Adult Student

Please return this signed form to the Principal by _________________________ Date

If you have any questions, please call the Principal at__________________