2013-2014 MEDIA RELEASE PERMISSION FORM

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(This form only applies to Mr. Prindle's Forensic Science and General Chemistry Classes)

Recording of various school and classroom activities through the use of photography, audio, and video equipment is done by Byron Center Public Schools throughout the year. The recording might circulate to other students or classrooms, be used in district publications, by district personnel in presentations at local, state, or national conferences, on the district website, staff website and/or the internet, or be shown on local TV.

If parents/guardians or students 18 years old or older approve of the use of photography, audio, or video transmission of your child/themselves, please fill this form and return it within five (5) days of receipt.

A copy of this form can be found at davidprindle.com

CHECK ONLY ONE CHOICE BELOW *

Please read each choice carefully.

You may use a picture of my child without identifying by name.

You may use a picture of my child using a first name only.

You may use a picture of my child including my child’s first and last name.

I do not wish to have my child photographed or video recorded during the 2013- 2014 school year.

IF YOU CHECKED ONE OF THE FIRST THREE STATEMENTS ABOVE, YOU MUST ALSO CHECK ONE OF THE STATEMENTS LISTED BELOW. *

I understand I am giving my permission for the district to use the information referenced in the above checked statements in all district publications, INCLUDING use on the district website, staff website and/or the internet and TV.

I understand I am giving my permission for the district to use the information referenced in the above checked statements in all district publications, EXCLUDING use on the district website, staff website and/or the internet and TV.

Required

Your Childs First and Last Name *

Current Grade *

Parent Digital Signature. By signing your FULL name you verify that the statements above are your express wishes. *

Today's Date *

Parent Email *

This may be used to verify that you signed the form

Submit

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