Student Media Release Consent Form

Student Name School Name Grade Parent/Guardian Name Contact Email

I hereby grant permission for my child named above to be interviewed, photographed, and/or videotaped for use by the school or district for educational, promotional, or newsworthy purposes in media including but not limited to publications, broadcasts, press releases, and websites.

I give consent for my child’s image and/or work to be used as described above. I do not give consent for my child’s image and/or work to be used.

Parent/Guardian Signature

Date