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Media Consent Form

Student's Name*

Answer required for "Student's Name"

Parent/Guardian's Name*

Answer required for "Parent/Guardian's Name"

Parent/Guardian's Email or Phone Number*

Answer required for "Parent/Guardian's Email or Phone Number"

Media Consent

Fannie Lou Hamer Freedom High School students participate in many activities that may be photographed and/or recorded for video. We ask that you grant your persmission for your child to be recorded. No photographs or recordings will be used for profit making purposes.

I consent to the participation in interviews, the use of quotes, and the taking of photographs, audio and/or video recordings of my student.

Answer required for "I consent to the participation in interviews, the use of quotes, and the taking of photographs, audio and/or video recordings of my student."

Yes

I have questions about this.

I grant Fannie Lou Hamer Freedom High School the right to edit, use, and reuse said products for non-profit purposes including use in print, on the internet, and all other forms of media. I hereby release the New York City Department of Education and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above.

Answer required for "I grant Fannie Lou Hamer Freedom High School the right to edit, use, and reuse said products for non-profit purposes including use in print, on the internet, and all other forms of media. I hereby release the New York City Department of Education and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above."

Yes

I have questions about this

Acknowledgement

Digital Signature of Person Completing this Form*

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Date*

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