Orchard Hill Elementary School

Montgomery Township Board of Education

Media Release Form

Orchard Hill Elementary School

 

Please complete Parts 1, 2 and 3 by responding either “yes” or “no” to each. Then complete the information at the bottom of this sheet and return it to your child’s teacher. Thank you for your cooperation.

 

 

Part One:

This is to certify that I give my permission for my son/daughter to be photographed or videotaped by the Board of Education representatives and for the photos and/or videotapes to be used in Board of Education publications, displays, television programs or news releases.

 

Please check on response:                    ____     YES            ____       NO

 

Part Two:

Upon occasion, local newspaper or television reporters visit our schools. I hereby give my permission for my son/daughter to be photographed or videotaped by representatives of the media and for the photos and/or videotapes to be used on local television broadcasts or in area newspapers. I understand that my child will not be interviewed by any newspaper or television reporter on Board of Education property without my consent.

 

Please check on response:                    ____     YES            ____       NO

 

Part Three:

The Montgomery Township Board of Education has its own Web Site on which information about our school district is disseminated. Photos, videos and student work are occasionally used on our Web Site, but the students involved are either not identified or identified by first name only.

 

I hereby agree to the use of my child’s photo, video and/or work on the Montgomery Township Board of Education Web Site as long as he or she is identified by first name only. If my child is to be identified by more than just first name on the web site, I understand that I will be asked to give explicit permission for this to be done on a case by case basis.

 

Please check on response:                    ____     YES            ____       NO

 

 

Student’s Name:

 (please print)

 

Student’s Teacher

 

Grade

Print name of Parent/Guardian:

(please print)

 

Parent/Guardian Signature:

(sign)

 

Relationship to Student:

 

Date:

 

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