New Hanover County Schools Student Image Permission Form

Dear Parent/Guardian:

Please read over the following and make a decision as to whether you grant permission for NHCS to post, print, or release your child’s image/photograph or student work.

Examples of how your child’s image/photograph or student work may be used:

• Appear in a printed publication such as a class picture, newspaper, magazine, or yearbook

• Submitted as samples to programs (examples: sports programs or play programs) or as contest entries to sponsors

• Utilized as a demonstration or sample in educational workshops, classrooms, and/or conferences

• Appear on video/electronic image made during a student presentation of a project, or in broadcasts or video/electronic image, which may or may not be used by a local television station or school/county project

• Other educational activity as NHCS deems necessary

Your child’s name or address WILL NOT be included with your child’s image/photograph or student work when published on the Web.


RELEASE AUTHORIZATION

Your permission grants NHCS approval to publicize without prior notification and remains in effect until NHCS receives written notice that you would like this revoked.

_______ I/We DO give permission for ‘s image/photograph or school work to be used as described above. We are willing to release this into the public domain.

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_______ I/We DO NOT give permission for ‘s image/photograph or work to be used as described above.

Parent/Guardian Name: _______________________________________________________________

Parent/Guardian Signature: ____________________________________________________________

Address: ___________________________________________________________________________

City, State, Zip Code: _________________________________________________________________

Phone Number _________________________________________________ Date: ________________

Please return this signed form to your child’s teacher.

Revised 06/13/2012