Videotape Release Form printable pdf download

Videotape Release Form

Secondary Teacher Certification in History and Social Sciences

Videotape Release Form

Note: If students who will be video-taped have already given general permission to be video-taped to

the school district, school, or teacher it is not necessary to complete this form. If students have not yet

given general permission to video-tape, please make sufficient copies of this form for each student in

the class or group to be videotaped.

*A parent or guardian must sign the form, unless the student is over 18.*

I, ___________________________, the undersigned, authorize the staff and/or student

teachers of Northern Illinois University and/or the staff of __________________

school district to record, film and videotape my / my child’s voice and image and to

photograph my / my child’s person.

Such voice and image recordings and photographs will ONLY be used for the purpose of

evaluating student teacher performance by the College of Liberal Arts and Sciences at

Northern Illinois University. Videotapes will be privately viewed by the student teacher,

the cooperating teacher(s), and NIU faculty and staff. If applicable, portions of the said

videotapes may be viewed for instructional purposes, to evaluate the performance of

the student teacher only, in a classroom setting.

I further state that I have carefully read the terms of this release. I understand that I am

signing a complete release and bar to any claim resulting from my participation in the

production named in this release.

___________________________

__________________________

Signature of participant

Signature of parent/guardian

___________________________

__________________________

Printed name of participant

Printed name of parent/guardian

_________________

Date

Videotape Release Form