CONSENT TO PHOTOGRAPH, FILM, OR VIDEOTAPE A STUDENT FOR NON-PROFIT USE (e.g. educational, public service, or health awareness purposes)
Please fill out the form below to authorize or not authorize photo, film, or videotape consent for your child.
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Email *
Student First Name *
Student Last Name *
Grade *
Official Class Code
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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. 63 Old South. I  also grant P.S. 63 Old South to 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. *
Signature of Parent/Guardian (By typing your name you are authorizing or not authorizing media consent of your child according to the yes/no answer above) *
Date *
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Address of Parent/Guardian *
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