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