Media Consent Form and Release
Chicago Public Schools
Email address
John B. Murphy Elementary School
3539 W. Grace St.
Chicago, IL 60618
Phone: 773-534-5223
http://murphy.cps.edu
Date
MM
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YYYY
Student ID Number
8 digit - ID Number
Your answer
Student First Name
Your answer
Student Last Name
Your answer
I hereby consent my child to be photographed, video taped, audio taped or interviewed by the Board of Education of the City of Chicago (the "Board") or the news media when school is in session or when my child is under the supervision of the Board might like to celebrate my child's accomplishments and work. Therefore, I further consent for the Board's release of information on my child's name, academic/non-academic awards and information concerning my child's participation in school-sponsored activities, organization and athletics.

I also consent to the Board's use of my child's name, photograph or likeness, voice or creative work (s) on the Internet or on a CD or any other electronic/digital media or print media.

As the child's parent or legal guardian, I agree to release and hold harmless the Board, its members, trustees, agents, officers, contractors, volunteers and employees from and against any and all claims, demands, actions, complaints, suits or other forms of liability that shall arise out of or by reason of, or be caused by the use of my child's name, photograph or likeness, voice or creative work(s), on television, radio or motion pictures, or in the print medium.

It is further understood and I do agree that no monies or other consideration in any form, including reimbursement for any expenses incurred by me or my child, will become due to me, my child, our heirs, agents or assigns at any time because of my child's participation in any of the above activities or the above-described use of my child's name, photograph or likeness, voice or creative work(s).

I understand that I may cancel my consent by providing written notice to the principal.

Parent Signature
Signature of Parent or Guardian of Student if age 18 or over
Your answer
Parent Email
Email will be used for submission purposes
Your answer
A copy of your responses will be emailed to the address you provided.
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