Media Consent Form: English Version

Media Consent Form

Consent to photograph, film, videotape a student, or use student work for non-profit use (e.g. educational, public service, or health awareness purposes).
Student Name: First Name* Last Name* .
School: Soundview Academy For Culture & Scholarship
I hereby consent to the participation in interviews, the use of quotes, and the taking of photographs, use of his or her classwork, movies or video tapes of the student named above by student name. I also grant to name of school 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(is student is under 18):
Signature of parent/guardian:*

Clear
Date*

MonthDayYear
Date
Address of Parent/Guardian:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty: