Rowland Academy Student Work and Image Release Form
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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Do you  wish to have your child photographed/videotaped or his/her work published by a representative of the  Harrisburg School District? *
Scholar's FIRST name (please complete a separate form for each child) *
Scholar's LAST name (please complete a separate form for each child) *
Grade level of scholar *
Homeroom Teacher *
Scholar's address *
Guardian's FIRST name *
Guardian's LAST name *
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 *
Relationship to scholar  (mother, father, step parent, foster parent, grandmother, grandfather, aunt, uncle, older sibling, etc.) *
Guardian's email address
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