NW Islamic School
Media Consent Form
NW Islamic School occasionally photographs and records students during school events, classroom activities, and special programs. These images and recordings may be used to celebrate student achievements, promote the school, and communicate with our community. This form allows parents/guardians to provide or withhold consent for media use.
Student Information
Student's Full Name:
Grade / Class:
Parent/Guardian Information
Parent/Guardian Full Name:
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Consent Options
I grant NW Islamic School permission to use my child's photograph, video, or likeness in the following (check all that apply):
School website
Social media platforms (e.g., Facebook, Instagram)
School newsletters and publications
Promotional materials and brochures
Classroom and hallway displays
Local media or press coverage
— OR —
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I do NOT grant permission for any media use of my child's image or likeness.
Conditions
Images will be used solely for educational and promotional purposes.
No student's full name will be published alongside their image without separate written consent.
Consent may be withdrawn at any time by submitting a written request to the school office.
This consent remains valid for the current academic year unless revoked.
Signature
"I have read and understood the terms above. I confirm my consent preferences as indicated."
Parent/Guardian Signature:
Date:
-
Month
-
Day
Year
Date
OFFICE USE ONLY
Received by:
Date Received:
-
Month
-
Day
Year
Date
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