Media Consent Form
This form must be filled out by the parent/guardian of every eighth grade student in order for the student to appear in any virtual school event, including graduation.
Email *
Consent to photograph, film, or videotape a student and post it for non-profit use (e.g. educational, public service, or health awareness purposes)
Student's Last Name *
Student's First Name *
Student's Homeroom Class *
Select your child's learning schedule: *
I hereby consent to the participation in interviews, the use of quotes, and the taking and use of photographs, movies, or video tapes of the student named above by MS 172. I consent to the publication of the image, video, voice, name, grade, and official class of the student named above in a virtual school function (e.g. Graduation, Senior Awards Night, National Junior honor Society Induction, etc.). I also grant to MS 172 the right to edit, use, and reuse said products for nonprofit purposes including use in print, on the internet, and all other forms of media including release of video through Google classroom and a YouTube premiers link. I also hereby release the New York City Department of Education and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above.
By typing my name I indicate my agreement as the parent/guardian of the student named above.
Parent/Guardian's First & Last Name *
Parent/Guardian's Email Address *
Parent/Guardian's Phone Number *
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