Student Release Form                                                                       Page I of I Student Release Form for Media Materials 
Date: 
Dear Parent/Guardian: 
I am a student at Appalachian State University, and I am working in your childs class as an intem. As a part of my class work, I may be required to shoot videotape, take photos or audiotape in the classroom. 
Any products I create will be reviewed by my professors at Appalachian State University who will handle the material confidentially. Please indicate below if it is permissible to include your child on videotape, in photographs and/or on audiotape, and return this to me by 
Thank you for your cooperation and assistance. Sincerely, 
Student Name: 
Check appropriate response: 
Yes, my child may be videotaped, audiotaped or photographed. 
No ,my child may not be videotaped, audiotaped or photographed. 
Parent/guardian signature:                                            Date: http://www.ced.appstate.edu/projects/partnership/block/media/release.htm                      11/21/99