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Consent To Photograph, Film, Or Videotape A Student For Non-Profit Use - New York City Department Of Education

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: ________________________________________________________________________

Signature of Student (if 18 or over): ____________________________________ Date: __________________

Address of Student: __________________________________________________________________________

Consent To Photograph, Film, Or Videotape A Student For Non-Profit Use - New York City Department Of Education