IJNDC-E4/MSAD #11 Media Release Form

File: IJNDC-E4

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
time.

_______ 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 Address___________________________________________________________

Home Phone Number ________________Work Phone Number ___________________

E-mail Address__________________________________________________________

Adopted: June 2, 2011