Student Photograph And Video Consent Form


September 2010
Student Photograph and Video Consent Form
The purpose of this parental/guardian consent form is to obtain permission for your child to
appear in any videotapes or photographs that are created for the purposes of improving
instruction or documenting important events at his/her school.
Photographs and video images of students in the Bangor School Department are often taken for
the purpose of celebrating student achievement and sharing educational programs with the
community. In addition, many of our teachers participate in courses that ask them to videotape
their teaching and then later critique their instructional practices. Your child may appear in one
or more of these video segments or photographs. Under no circumstances will the district
release personally identifiable information with such images, other than the child's first name
and grade.
Please check one of the following choices:
___ I/We GRANT permission for a photo/video image that includes this student to be shared
by the Bangor School Department.
___ I/We DO NOT GRANT permission for this student's photo/video image to be shared by
the Bangor School Department
Student's Name (
please print) _______________________________ Grade ________________
Name of Parent/Guardian
(please print)
Signature of parent/guardian ______________________________ Date __________________


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