Parental Permission Form Concerning

Disclosure of Student Images, Recording, and Schoolwork

The Roosevelt Union Free School District is committed to protecting the privacy and safety of all students. There are times when teachers and administrators feel it is appropriate to recognize students and their work in a public forum. Examples of such recognition include publishing a team roster on a school’s web page, exhibiting student art work on the web, and inviting local media to report on special school events. In order for your student to be included in these types of recognition, we need your permission to disclose your student’s photograph, name, voice, and schoolwork. Roosevelt UFSD appropriate school related events.

Yes No
I give I do not give
permission permission
to RUFSD to RUFSD
to: to:

_______ _______ Disclose my child’s name

_______ _______ Disclose my child’s photograph or videotape of his/her image

_______ _______ Disclose copies of my child’s school or extracurricular work
(for example art, poetry, or other writings)

_____________________________ __________________________
Printed name of student School

_______________________________ __________________________
Printed name of Parent/Guardian Grade

_______________________________ __________________________
Parent/Guardian Signature Date

Please sign and return this form to your child’s school.