Please indicate your preference below.
SELECT YES or NO:
*
YES - My child's photograph/video/interview may be reproduced and released for use in the media.
NO - My child's photograph/video/interview may NOT be reproduced and released for use in the media.
Student Last Name
*
Student First Name
*
Student ID #
*
Note: If you do not have a Student ID because you are not currently an MDCPS student, please write "NOT MDCPS Student" above.
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Legal Guardian - Signature
*
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
SCHOOL NAME:
CONTACT PERSON:
SCHOOL TELEPHONE:
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