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CONSENT TO PHOTOGRAPH, FILM, OR VIDEOTAPE A STUDENT FOR NON-PROFIT USE
(e.g. educational, public service, or health awareness purposes)
Student Name: _________________________ School: _________________________
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: __________________________________________________________________________
consent_form_revised35.pdf (PDF, 17.28 KB)
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