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Office of Communications and Media Relations
52 Chambers Street, New York, NY 10007
Tel: 212.374.5141 Fax: 212.374.5584
CONSENT TO PHOTOGRAPH, FILM, OR VIDEOTAPE A STUDENT FOR NON-PROFIT USE
(e.g. educational, public service, or health awareness purposes)Student Name: _________________________________ School: _________P.S. 204______________________
I hereby consent to the participation in interviews, the use of quotes, and the taking of photographs, movies or video tapes of the Student named above by .I also grant to 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 also 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.
Signature of Parent/Guardian (if Student is under 18): _____________________________ Date: _______________
Address of Parent/Guardian: ________________________________________________________________________
OR
Signature of Student (if 18 or over): ____________________________________ Date: __________________
Address of Student: __________________________________________________________________________