Limited Release for Publication of Student Image

Photographs

During the school year there may be opportunities for your student’s photograph to be used in various ways. Please mark your preferences regarding each of the possible uses of your student’s photograph. District policy prohibits identification by name of individual students on district websites.

I DO or I DO NOT want my student’s photograph to appear in a local newspaper.

I DO or I DO NOT want my student’s photograph to appear on television.

I DO or I DO NOT want my student’s photograph to appear on the district website.

I DO or I DO NOT want my student’s photograph to appear in any newsletter or other printed classroom material.

Videotapes

The district often has student teachers from local colleges and universities. As part of their student teaching experiences they are required to submit a video tape of their teaching to their supervisors as a part of the evaluation process. District teachers may also videotape a class to record a class play, presentation, or to improve their own teaching.

I DO or I DO NOT want my student to be videotaped by a student teacher.

I DO or I DO NOT want my student to be videotaped by a district employee.

Signatures

Student Name _______________________________________ Grade _____________

(Please Print)

___________________________________________________ Date ______________

Student Signature

___________________________________________________ Date ______________

Parent/Guardian Signature