Student Release Form for Media Materials

 Date:__________

Dear Parent/Guardian:

I am a student at Appalachian State University, and I am working in your child's class as an intern.    As a part of my
class work, I may be required to shoot videotape, take photos or audiotape in the classroom.  I may also copy
(photocopy, scan, videotape or photograph) student work.

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: _______