Consent Form

Consent to Photograph, Film, or Videotape a Student for Non-Profit Use

(eg. education, 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 videotapes 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

OR

Signature of Student (if 18 or over)

Date

Address of Parent/Guardian