Pine Lake Preparatory Media Declination Form

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Please sign and submit this form ONLY if you do NOT grant permission to Pine Lake Preparatory to use your child's photograph, voice, or other likeness. Please note that if Pine Lake Preparatory does not have this form on file that your permission is implied.

Student Name (first and last name) *

Please enter one child's name. If you have multiple children at PLP, please submit one form per child.

Grade level

Kindergarten

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

Grade 7

Grade 8

Grade 9

Grade 10

Grade 11

Grade 12

Clear selection

I do NOT give consent to Pine Lake Preparatory to use and/ or reproduce photographs, likenesses or the voice of my child/ children in any legal manner for the internal or external promotional/informational activities of Pine Lake Preparatory.

Please type your full legal name to DECLINE media consent.

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