SAMPLE
XYZ Charter
719
555/555-1234
School Publicity/Educational Purposes
In a typical school year, there are numerous positive activities in the schools that merit news coverage. Often the news media will want to include student pictures in their coverage. In addition, during the school year teachers and other school personnel may audio/videotape and/or photograph students involved in learning activities. Educators may use these audio/videotapes and/or photographs to demonstrate teaching and learning techniques and environments. If for some reason you as a parent or guardian Do Not want your child photographed or audio/videotaped for school publicity/educational purposes, please complete the form on this page. If this form is not signed and returned to the principal within 10 days after the issuance of this notice, it is assumed that XYZ Charter has your permission to photograph or audio/videotape your child for school publicity/education purposes.
During the 20__-20__ school year, I, _______________________________, parent or
Print Parent Name
guardian of ______________________________, Do Not want the above named child to
Print Student
Name
appear for school publicity/educational purposes in a photograph or audio/videotape where
the child can be easily recognized or identified.
______________________________________ ______________________________
Parent signature Date
A specific request will be sent home by the school should a corporation or non-school entity ask to audio/videotape students for use in a film produced by that corporation or entity.
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