• doe

    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:  __________________________________________________________________________