Take-Pause Student Media Release Form
Have your parent/guardian alongside you whilst you fill out the entirety of this form.
Email *
Date today *
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Student Name *
Parent/Legal Guardian Full Name *
Relationship to student *
Student's School *
Take-Pause is designing a system to reduce stress and anxiety in teenagers. We are gathering; feedback to improve the system, data on student stress levels, and stories of students using Take-Pause. *
I, with name as stated above, being the child's parent or legal guardian, consent to the collection of feedback and data, and the publication of recorded media which include and identify my child, whether such use be for public information, or any campaign relating to the mission of Take-Pause.
Required
Digital Signature *
I, with name as stated above, being the child's parent or legal guardian, certify that I have read the Media Consent and Release statement and fully understand its terms and conditions
Required
A copy of your responses will be emailed to the address you provided.
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