Media Release Form For Students - Acadia Parish School Board printable pdf download

Acadia Parish School Board

Media Release Form for Students

Student Name: ________________________________________________________________

School Name: ________________________________________________________________

Parent or Guardian Name: _______________________________________________________

I give permission to use my child’s video, photograph, and/or work (such as artwork, writings,

etc.) for publication.

Any video made will be for professional development and/or instructional use in schools and

classrooms in Acadia Parish. The video may show presenter/teacher and various students, but

the students may be referred to by, or wear nametags with, first names only and will not be

referred to by last names.

Any photographs or works may appear on the Acadia Parish School Board website and/or

school website. Students in grades Pre-K through 8 may be referred to by class name only, and

no personal information will be released. Students in grades 9 through 12 may be referred to by

first name and last initial only, and no other personal information will be released.

newspaper publications, students in Pre-K through 12 may be referred to by first and last

names.

(This section to be completed by School Administrators before issuing to students.)

If you have any questions or comments, please feel free to contact:

Name: ______________________

Phone: ___________________________

School/Dept: ______________________

Email: ___________________________

I am the parent or legal guardian of the child named above. I have read and understand the

information regarding publication of my child’s video, photograph or works.

(Check only one)

_____ I DO give permission to use my child’s image or work as described above. This

permission is valid as long as my child is enrolled in the Acadia Parish School District. I

understand that I may revoke this permission at any time by notifying in writing the

school my child currently attends.

______ I DO NOT give permission to use my child’s image or work as described above.

I understand, for the making of any instructional video, my child will be removed from

the classroom and he/she will receive alternate instruction elsewhere.

Signature of Parent/Guardian: __________________________

Date: _________________

Signature of Student: _________________________________

Date: _________________

Return the completed Media Release Form to your child’s current school.

(08-05-2009)

Media Release Form For Students - Acadia Parish School Board