•  

    COATESVILLE AREA SCHOOL DISTRICT

    “Excellence in Education”

     

    MEDIA RELEASE FORM

     

     

     

    Student Name: __________________________________     Grade:  ­­­­­­­­­­­­­­­­­_____________

                                                              Print Name

    School Name: ________________________________     Date: __________________


    The Coatesville Area School District is committed to protecting the privacy of all students and their families.  The following is provided to offer you as a parent the right to choose whether or not your child may be photographed, videotaped, or recorded for the local news media, publicity or for internal purposes, such as newsletters, school and district presentations, district advertisements, district web sites, etc.
     
    I, ____________________________, the parent of, _________________________, hereby give my full and complete permission, without reservation or restriction, for my child to be photographed, (still or motion), and/or tape recorded, (audio or video), by employees of the Coatesville Area School District, its education partner organizations, and/or agents of the media.


    ______        I understand and agree that I am hereby waiving all claims to the use of said photographs, slides, films, videotapes, audiotapes, or other audiovisual representations taken or made of my child.


    ______   I do not wish to allow my     child to be photographed, videotaped, or recorded.


    Please Print:

    ______________________________              ______________________________
    Name of Parent/Guardian                                   Signature

    ______________________________________                           ________________
    Address                                                                                                Date                                                                            

    ___________________________________                               _________________
    City                                                                                                    State, Zip

    ____________________          ___________________         ___________________

    Home Phone Number                 Work Phone Number               Cell Phone Number

     

    Coatesville Area School District.  Do not change or modify this form.  KAS 06/09