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Consent to Photograph, Film, or Videotape a Student for Non-Profit Use
2020-2021
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* Indicates required question
Student's First and Last Name
*
Your answer
Class
*
Choose
PreK 201
PreK 202
K-209
K-211
K-212
K-213
1-203
1-305
1-313
2-301`
2-307
2-309
3-303
3-311
4-503
4-509
5-501
5-506
5-508
6-504
6-412
6-413
7-505
7-507
8-406
8-512
8-409
School
*
Your answer
I hereby consent to the participation in interviews, the use of quotes, and the taking of photographs, movies or video tapes of the Student named above by P.S./I.S. 192.
*
Yes
No
I also grant to P.S./I.S. 192 the right to edit, use, and reuse said products for non- profit purposes including use in print, on the internet, and all other forms of media.
*
Yes
No
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.
*
Yes
No
Parent's First and Last Name
*
Your answer
Date
*
MM
/
DD
/
YYYY
Parent or Guardian's Address
*
Your answer
Comments:
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