PARENTAL PERMISSION FOR THE RELEASE
AND PUBLICATION OF STUDENT’S PHOTOGRAPH/IMAGE

Parental permission is required annually for the school district to use or publish a student’s photograph in building and district publications.  Permission must also be granted if the information and/or photos are released to the media and newspapers.

Please read and complete the form below.  Check the box (es) that will apply to your child

STUDENT NAME ____________________________________    DATE OF BIRTH________________

HOME ADDRESS ___________________________________________________________________

TELEPHONE NUMBER _______________________________________________________________

SCHOOL BUILDING ___________________________________________    GRADE______________

q  I authorize the Board of Education, its officials, employees and agents to use my child’s photograph/image as “directory information” and to use, release, and/or publish my child’s photograph/image in ALL SCHOOL PUBLICATIONS including the calendar, yearbook, annual report, district newsletter, media releases, athletic and music programs, play programs, etc.  It may also be used in the student newspaper.

q I authorize the use of my child’s image on the district Web site.

q I do not authorize the use of my child’s photograph/image in any school related publications including, but not limited to, sports programs, newsletters, yearbook, school displays or media releases.

Parent/custodian’s signature _________________________________________    Date_____________

THIS FORM SHALL REMAIN IN EFFECT FOR THE 200__ - 200__ SCHOOL YEAR.