Consent to Photograph, Film, or Videotape A Student for Non-Profit Use (e.g. educational, public service, or health awareness purposes)

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There are many occasions during the school year when students may participate in activities which are preserved in photographs, movies, slides, or videos. Please complete the form as consent for your child to appear in photographs, videos, etc ... which are related to school activities including, but not limited to ...

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 below .I also grant to Myra S. Barnes, I.S. 24 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. 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

Required

Student LAST Name *

Student FIRST Name *

Class# (choose one only) *

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By checking this box and typing my name below, I am electronically signing this photo & video consent form as described in the list above. *

I am electronically signing this form.

I am the legal parent/guardian of the student noted in this form.

By typing my name in the next question, I am electronically signing this document.

Required

Parent ONLY, type full name below (electronic signature) This is considered a legal signature. *

Date (electronic signature) *

YYYY

Cell Phone # of Parent Completing this Form *

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