Media Release Form

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Media Release Form

Purpose of the Media Release Form

This form provides consent for the school to use photos, videos, and other media featuring current and former students in various promotional and informational materials. These may include printed materials, websites, social media posts, TV segments, and other media outlets. It also allows for the release of such media to external reporters visiting the school. As a parent or guardian, this form offers you the choice to disallow the use of your child’s name, image, or schoolwork in such media.

By signing this form, I, the undersigned parent or guardian of the named student, acknowledge and agree to the following:

1. Consent to Use of Media
I grant permission for the school to use photos, videos, and other media featuring my child for:

Printed publications and promotional materials
School and district websites
Social media posts
Television broadcasts or online videos
Media releases provided to journalists and other media outlets

2. Assumption of Responsibility
If the “do not” box is selected, I acknowledge that the school will make every reasonable effort to ensure my child’s name, image, and schoolwork are not used in media. However, I understand that accidental use may occur, and I release the school from any liability in such cases.

3. Automatic Consent in Absence of Form
I understand that if this form is not returned to the school, it will be considered that consent for media use has been granted.

4. Revocation of Consent
I understand that I may revoke my consent at any time by providing written notice to the school. The school will make every effort to honor this change moving forward.

5. Questions and Clarifications
Any questions or concerns regarding the school’s media release policy, state laws, or related issues can be directed to the Main Office at:

Address
Email
Phone Number

Please indicate your preference by selecting an option below and submitting this form:

I hereby grant permission for the reproduction and publication of my child's photograph(s) in any school-related media.

I do not grant permission for the reproduction and publication of my child's photograph(s) in any school-related media.

Please fill out student information below.

Student First Name: *

Student Last Name: *

Grade:

Please fill out parent or guardian information below.

Parent/Guardian Full Name: *

Parent/Guardian Phone Number: *

Parent/Guardian Email: *

By signing this agreement, I acknowledge that I am the parent or guardian of the student and am providing consent for the school to either include or exclude my child from any media-related activities, including photography, video recordings, or other media content. I understand that while the school will make every reasonable effort to comply with this request, it cannot guarantee exclusion from all media, especially in public or group settings. I agree to communicate any changes to this preference in writing to the school.

Use the space above to sign your name