Media Release English

HOUSTON INDEPEDENT SCHOOL DISTRICT
STUDENT MEDIA CONSENT AND RELEASE FORM
This release allows the Houston Independent School District (HISD) to print, photograph, and record my child for use in efforts to promote HISD's activities and achievements. The consent includes allowing my child to be included and/or featured in materials to train teachers and/or increase public awareness of HISD schools through digital and print media including: newspaper, radio, TV, websites, blogs, and social media channels (Facebook, Twitter, YouTube, etc, DVDs, displays, and brochures. This release includes the use of my child's work, name, image, and/or voice.

Please select one of the two statements below.
I attest that I am the parent or guardian of ______________ and I GIVE HISD and its employees andrepresentatives permission to print, photograph, and record my child for use in electronic, digital, andprinted media.
Student Name
I attest that I am the parent or guardian of _____________ and I DO NOT GIVE HISD and itsemployees and representatives permission to print, photograph, and record my child for use in audio,video, film or any other electronic, digital, or printed media.
I agree to release the Houston Independent School District, its past, present and future trustees, officers, employees, representatives, and agents, from any and all liability, claims, demands, and causes of action arising out of the use of this material. I certify that I have read this document and fully understand its terms and conditions. I also understand that I may withdraw consent at any time by sending a written request to the principal of my child's school.
Name of child*
Grade*
Student ID Number*
Address*

Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Name of parent or guardian*
School*
Signature of parent or guardian*

Clear
Date*

MonthDayYear
Date
Phone Number
HISD Media RelationsIJuly 2018
Should be Empty:

HOUSTON INDEPEDENT SCHOOL DISTRICT

STUDENT MEDIA CONSENT AND RELEASE FORM