consent form revised35 (PDF)




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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: _________________________

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: __________________________________________________________________________






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