student videotape/photograph release form

As the parent/legal guardian, I hereby give ________________________ permission to use the physical likeness, person, picture and/or voice of my child/children in the production and duplication of  “___________________________________________.”

I understand that the video/photography of my child/children will be used for educational purposes (which may include open and/or closed circuit broadcasting and which may be viewed on video, television, the Internet and other media). I understand that ______________________ has the right to edit the video and/or voice as necessary.

I understand that no personal information about my child, other than his or her physical likeness, person, picture and/or voice, will be released in written, videographic or photographic form.

I further understand that there will be no financial payment or other remuneration to my child/children or myself, either for initial or subsequent transmission or playback.

I understand that ownership of the video/ photograph remains solely with _____________________________.

I acknowledge that I have read this Videotape/Photograph Release Form document and agree to its terms.

Name of child/children: ____________________________________________

Parent/legal guardian name: __________________________________________

Parent/legal guardian signature: _______________________________________

ADDRESS: ___________________________________________________

TELEPHONE NO.: ______________________________________________

DATE: ________________________________________________________