6141.322 Form #2

SEYMOUR PUBLIC SCHOOLS

Seymour, Connecticut

Parent/Guardian and Student Permission to Publish

Student Group Photograph/Video/Film on the WWW Seymour Public Schools Website or Internet

Dear Parent/Guardian and Student (if 18 years of age or older):

The Seymour Public Schools would like to publish an original work created by your child on the World Wide Web (WWW), a part of the Internet.  It will be available to a global audience and will identify the students by group name only, e.g., Mr. Smith's Science Club.  This precautionary measure attempts to protect your student from possible rude, insulting or exploitative Internet Users.

Description of Photograph/Video/Film

Title: ___________________________________________________________

Purpose: __________________________________________________________________________

Publishing and Sponsoring Information:  ___________________________________________________

______________________________________________________________________________

Sponsoring School or Office:  __________________________   Telephone #: ___________________________

Name of Employee Requesting Permission: _________________________________________

Name of Website:   URL: http:// __________________________

Please check one:

(If permission is granted, all monetary claims upon the District are relinquished and consent is given to the use of the group name, likeness, or voice of the child in connection with publicity and promotion.)

[  ]  We the parent/guardian and student DO grant permission
[  ]  We the parent/guardian and student DO NOT grant permission
[  ]  I am a student of 18 years or older and DO grant permission
[  ]  I am a student of 18 years or older and DO NOT grant permission

______________________________________        ________________________                 ______________
Signature of Parent/Guardian                                         Name (Please Print)                             Date

______________________________________        ________________________                 ______________
Signature of Student (18 or older)                                  Name (Please Print)                             Date

Please return signed form to the employee at the sponsoring school or office

Adopted:  Seymour Board of Education August 3, 2020