VIDEO RELEASE FORM 

This is provided as an example only.  Your organization may already have an approved form.

Dear Parent/Guardian:

The _____________________________ School District requests your permission to reproduce through printed, audio, visual, or electronic means activities in which your pupil has participated in his/her education program. Your authorization will enable us to use specially prepared materials to (1) train teachers and/or (2) increase public awareness, fundraise and promote continuation and improvement of education programs through the use of mass media, displays, brochures, websites, etc.

1. Name of Pupil (please print)

_________________________

2. Birthdate (please print)

_____________________

3. Name of Parent (please print)

_________________________

a. I, as a parent or guardian, of the above named pupil fully authorize and grant the School District and its authorized representatives, the right to print, photograph, record, and edit as desired, the biographical information, name, image, likeness, and/or voice of the above named pupil on audio, video, film, slide, or any other electronic and printed formats, currently developed, (known as “Recordings”), for the purposes stated or related to the above.

b. I understand and agree that use of such Recordings will be without any compensation to the pupil or the pupil’s parent or guardian.

c. I understand and agree that the School District and/or its authorized representatives shall have the exclusive right, title, and interest, including copyright, in the Recordings.

d. I understand and agree that the School District and/or its authorized representatives shall have the unlimited right to use the Recordings for any purposes stated or related to the above.

e. I hereby release and hold harmless the School District and its authorized representatives from any and all actions, claims, damages, costs, or expenses, including attorney’s fees, brought by the pupil and/or parent or guardian which relate to or arise out of any use of these Recordings as specified above. _____________________________________________________________________________________

My signature shows that I have read and understand the release and I agree to accept its provisions.

4. Signature of Parent/Guardian  

_________________________

5. Date Signed

_____________________

6. Address (Number, Street, Apartment Number)

__________________________________

7. City

_____________________

8. State

________

9. Zip Code

__________

Please return completed form to school. While granting of permission is voluntary, because of the nature of today’s technology, we cannot guarantee that your child will not be photographed or recorded while on school grounds or during school activities.

This form shall not be amended without written approval by the school district. 

Download a copy here: Release Form