2021-2022 Media Release Form - Miami Southridge Magnet Programs

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*

MonthDayYear
Date
Parent/Legal Guardian - Signature*

Clear
Date*

MonthDayYear
Date
SCHOOL NAME:
CONTACT PERSON:
SCHOOL TELEPHONE:
Should be Empty:

Please indicate your preference below.