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IJNDC-E4/MSAD #11 Media Release Form
MSAD #11 MEDIA RELEASE FORM
PARENT/GUARDIAN AGREEMENT FORM TO PUBLISH STUDENT INFORMATION
School_________________________________________ Date Returned______________
Student Name___________________________________ Grade_____________________
Home Room Teacher _______________________________________________________
_______ I would not like my child's picture put in the school or district newspaper(s) at any
_______ I give my permission to put my child's picture in the district school newspaper(s)
at any time.
_______ I would not like my child's picture posted on the Internet at any time.
_______ I would not like my child's work posted on the Internet at any time.
Signature of Parent or Guardian _____________________Date____________________
Home Phone Number ________________Work Phone Number ___________________
Adopted: June 2, 2011