Student Photograph And Video Consent Form printable pdf download

Student Photograph And Video Consent Form

September 2010

Student Photograph and Video Consent Form

The purpose of this parental/guardian consent form is to obtain permission for your child to

appear in any videotapes or photographs that are created for the purposes of improving

instruction or documenting important events at his/her school.

Photographs and video images of students in the Bangor School Department are often taken for

the purpose of celebrating student achievement and sharing educational programs with the

community. In addition, many of our teachers participate in courses that ask them to videotape

their teaching and then later critique their instructional practices. Your child may appear in one

or more of these video segments or photographs. Under no circumstances will the district

release personally identifiable information with such images, other than the child's first name

and grade.

Please check one of the following choices:

___ I/We GRANT permission for a photo/video image that includes this student to be shared

by the Bangor School Department.

___ I/We DO NOT GRANT permission for this student's photo/video image to be shared by

the Bangor School Department

Student's Name (

please print) _______________________________ Grade ________________

School

Teacher

______________________________

_______________________

Name of Parent/Guardian

_________________________________

(please print)

Signature of parent/guardian ______________________________ Date __________________

Student Photograph And Video Consent Form