Student Media Release Form
Student Media Release Form
[School/Organization Name]
[School/Organization Address]
[School/Organization Phone Number]
[Date]
Student Information
Student Name:
Grade:
Date of Birth:
Parent/Guardian Name:
Parent/Guardian Phone Number:
Parent/Guardian Email Address:
Media Release Permission
I, the undersigned parent/guardian of the student named above, hereby grant permission to [School/Organization Name] and its employees, agents, and representatives, to:
[Specify the types of media allowed]: Photograph, video record, audio record, etc.
[Describe the purpose of the media]: Use for educational, promotional, marketing, or other purposes.
[Specify where the media will be used]: School website, social media platforms, brochures, newsletters, etc.
Specific Details:
Event/Activity: [State the specific event or activity the media will be taken at]
Date(s): [Date(s) of the event/activity]
Location: [Location of the event/activity]
Limitations (optional):
[If there are any limitations on the use of the student’s image or voice, please specify them here. For example, you may want to limit the use to specific platforms, exclude certain types of images, or request that the student’s full name not be used.]
Release and Authorization
I understand that:
This release is voluntary and I may revoke it at any time by providing written notice to the school/organization.
My child will not be compensated for the use of their image or voice.
[School/Organization Name] will use reasonable efforts to protect the privacy and safety of my child.
By signing below, I acknowledge that I have read and understood this release form and I am authorized to sign on behalf of the student.
Parent/Guardian Signature:
Date:
Print Name:
[Optional: Witness Signature and Date]
Student Media Release Form :
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