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