Parent Syllabus Signature Authorization Form
If you have any questions about the syllabus or accompanying authorization form below, please feel free to contact Mr. Robbins immediately via his school email at todd.robbins@watertown.k12.ma.us
Student Name: *
First Last
Your answer
Semester: *
Course: *
Class Period: *
Follow the link below to view syllabus for your class:
I have read and understand the class syllabus and the expectations set forth. *
By checking the accompanying box, you are accepting the terms of the syllabus as stated.
Required
Audio, Image, and Video Release Statement:
I hereby grant WATERTOWN HIGH SCHOOL / DIGITAL MEDIA & COMMUNICATIONS (WHS / DMC) the irrevocable and unrestricted right to use and publish audio, photographs, video, or other images of me/my child, or in which I/my child may be included, in any print, electronic, digital or other media; and to alter the same without restriction. I further acknowledge that my son’s/daughter’s participation is voluntary, part of the course curriculum, and that I/they will not receive financial compensation of any type associated with the taking or publication of these images. I irrevocably assign such media rights and uses to WHS / DMC into perpetuity. I hereby release WHS / DMC and its legal representatives and assigns from all claims and liabilities relating to said media.
I have read and understand the Audio, Image, and Video Release Statement. *
By checking the accompanying box, you are accepting the terms of the Audio, Image, and Video Release Statement as stated.
Required
Film/Video Permission Statement:
Occasionally, film/videos are used in the classroom in order to illustrate a particular curricular-related concept. This statement serves as notification that we will be watching films/videos that may contain adult language/content.
I have read and understand the Film/Video Permission Statement. *
By checking the accompanying box, you are accepting the terms of the Film/Video Permission Statement as stated.
Required
Cell Phone Use Policy Statement:
The following is my cell phone use policy that will be strictly enforced in class.

Mr. Robbins’ classes and all of WCA-TV / WCA-Radio are CELL PHONE FREE ZONES. Students are prohibited from using their cell phone without express consent of the instructor. Such consent will only be given for clear and expressed academic necessities. If permission is not sought or expressly granted, all uses will be considered a “recreational” use of the cell phone and as such will be subject to the following consequences (at a minimum):

1. Student will lose participation credit for the class period and receive a session to be served within 24-hours of the offense.

2. A second or subsequent, offense will result in a referral to the Dean of Students for further action.

3. In addition, all second or subsequent offenses will result in an email notification of the student's parent/guardian.

I suggest silent mode or in your backpack during my class.

Students should feel free to enjoy the company of the amazing people in this class only!

This policy is consistent with the WHS Student Handbook policy already outlined for you.

I have read and understand the Cell Phone Use Policy Statement. *
By checking the accompanying box, you are accepting the terms of the Cell Phone Use Policy Statement as stated.
Required
Parent Signature: *
By typing your name in the accompanying box below, it is serving as your electronic signature, and you are stating that you have read and understand the class syllabus/release, and understand the expectations set forth.
Your answer
Relationship to Student *
Your answer
Parent Email Address: *
Will be used for Newsletters with Course Program Information
Your answer
Date: *
XX / XX / XXXX
Your answer
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