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Rowland Academy Student Work and Image Release Form
STUDENT ACADEMIC WORK AND IMAGE (PHOTOGRAPHING/VIDEOTAPING) RELEASE
Checking the space provided will clearly indicate that you DO or DO NOT wish to have your child's work or image used by the Harrisburg School District in any publication(s) including the District Website and websites used for instructional purposes.
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* Indicates required question
Do you wish to have your child photographed/videotaped or his/her work published by a representative of the Harrisburg School District?
*
I DO give permission for my child to be photographed, videotaped, or have his/her work displayed.
I DO NOT give permission for my child to be photographed, videotaped, or have his/her work displayed.
Scholar's FIRST name (please complete a separate form for each child)
*
Your answer
Scholar's LAST name (please complete a separate form for each child)
*
Your answer
Grade level of scholar
*
5th
6th
7th
8th
Homeroom Teacher
*
Your answer
Scholar's address
*
Your answer
Guardian's FIRST name
*
Your answer
Guardian's LAST name
*
Your answer
Electronic Signature of Guardian - acknowledging that you are an adult (over 18), the guardian of the above scholar and able to give consent for media release
*
Your answer
Relationship to scholar (mother, father, step parent, foster parent, grandmother, grandfather, aunt, uncle, older sibling, etc.)
*
Your answer
Guardian's email address
Your answer
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