Last Name ___________________ First Name ____________________ Grade _______
Please complete the following information.
Please Check One:
_____ I give my permission for my child’s image in the form of a scanned photograph, digital phtograph, or video clip to be posted on the World Wide Web as part of a school-developed page.
_____ I do not give my permission for my child’s image to be posted on the World Wide Web as part of a school developed page.
Please Check One:
_____ I give my permission for my child’s school work to be posted on the World Wide Web as part of a school developed page.
_____ I do not give my permission for my child’s school work to be posted on the World Wide Web as part of a school developed page.
Please Check One:
______ I give my permission for my child’s name (circle: first name/last name/both) to be used in conjunction with a picture and/or my child’s school work on the World Wide Web as part of a school-developed page.
_____ I do not give my permission for my child’s name to be used in conjunction with my child’s picture or school work on the World Wide Web as part of a school developed page.
Please print the following information:
Parent or Guardian Name : _______________________________________
Home Address: ________________________________________________
City, State, Zip: ________________________________________________
Home Phone: __________________________________________________
Parent Signature: _______________________________ Date: ___________
This form should be
returned to the school as soon as possible.
Thank you!