Correspondent Program Consent Form

Fall 2022

Dear Families,

Congratulations on your student’s involvement in Healthy NewsWorks. I’m writing to ask for your consent to potentially share your student’s work as described below.

By way of background, the Healthy NewsWorks program seeks to increase school and
community awareness about health, fitness, nutrition, and safety. Our students are involved in a range of newspaper and digital media activities and projects such as conducting interviews and research, writing articles, and creating illustrations.

We know how proud our students are when their work is shared by their school’s website or social media. With your consent, Healthy NewsWorks may share your student’s work, taped interviews and photographs in its health newspapers, on its website, on its social media sites, and through e-newsletters and other communications. If you are comfortable with our doing so, please click the button below and complete the form.

Please email me if you have any questions at muhlman@healthynewsworks.org.

You can learn more about Healthy NewsWorks at our website: www.healthynewsworks.org and follow along with exciting experiences on our Facebook, Instagram, and Twitter accounts.

Sincerely,

Marian Uhlman
Executive Director

CONSENT, ASSIGNMENT AND RELEASE
I (as parent or guardian) and the child (identified below) each irrevocably consent to and authorize Healthy NewsWorks, its officers, directors, employees, volunteers, and agents and any person or entity it so authorizes to use, reproduce, perform, broadcast, and display all photographs, video, audio and other images, student writings and student illustrations related to Healthy NewsWorks (together, the “Material”) taken of and/or produced by the child identified below, including identification of the child by name, for advertising, publicity purposes, and/or display, including but not limited to any publication, broadcast, social media, multimedia display and the world wide web publication, without compensation or any other consideration to me or the child.

All such Material and all rights therein, including but not limited to copyrights, are assigned to and shall constitute the property of Healthy
NewsWorks, solely and completely.

I and the child hereby release and forever discharge Healthy NewsWorks, its licensees, officers, directors, employees, volunteers, participating schools and school districts, and agents for any and all claims arising out of or in connection with the use of the Material.
I hereby certify that I am the parent guardian* of
*

Child's First Name Child's Last Name
Intending to be legally bound, I give my consent and agreement to the above child on behalf of him or her.
Name of Child's School *
Grade of Your Child *
Parent or Guardian Name *
(Print your full name)
Name of Your Child's Teacher
(Print their full name)
Parent of Guardian Signature *

Clear
Today's Date *

Month Day Year
Date
Address
City, State, Zip
Cell Phone Number
(Healthy NewsWorks will use for notifications only and will NOT share.)
Parent or Guardian Email *
Should be Empty:

CONSENT, ASSIGNMENT AND RELEASE