Student Information Sheet (Page 3 of 4) in pdf

Student Information Sheet Page 3

APPENDIX C

Nikolai Vitti

Superintendent of Schools

1701 Prudential Drive

Jacksonville, FL 32207-

8182

904.390.2000

MEDIA RELEASE—Student

DCPS Productions or outside organization, including news media

I , ____________________________________, hereby authorize the

videotaping/filming/photography of my child, ______________________________,

and/or the release of his/her name and achievement(s) for publishing (print, World Wide

Web) and/or broadcasting purposes. I also consent to the showing of the

video/film/photographs to any person. I understand that the Duval County School District

is not a party to outside organizations’ photography/filming/video production and will

hold Duval County Public Schools and its employees harmless from any liability in

connection with a production not produced internally by Duval County Public Schools.

___________________________________

Signature

___________________________________

Print Name

___________________________________

Date

Student Information Sheet Page 3