Fillable Printable Parental/Guardian Consent Form

Parental/Guardian Consent Form

We are sending you this parental consent form to both inform you and to request permission for

your child’s photo/image and personally identifiable information to be published on the district

and/or school’s web site.

As you are aware, there are potential dangers associated with the posting of personally

identifiable information on a web site since global access to the Internet does not allow us to

control who may access such information. These dangers have always existed; however, we

as schools do want to celebrate your child and his/her work. The law requires that we ask

for your permission to use information about your child.

Pursuant to law, we will not release any personally identifiable information without prior written

consent from you as parent or guardian. Personally identifiable information includes student

names, photo or image, residential addresses, e-mail address, phone numbers and locations and

times of class trips.

If you, as the parent or guardian, wish to rescind this agreement, you may do so at any time in

writing by sending a letter to the principal of your child’s school and such rescission will take

effect upon receipt by the school.

Check one of the following choices:

! I/We GRANT permission for a photo/image that includes this student without any other

personal identifiers to be published on the school and/or district’s public Internet site.

! I/We GRANT permission for this student’s photo/image and name to be published on the

school and/or district’s public Internet site.

! I/We GRANT permission for this student’s photo/image and all other personal identifiers

listed above to be published on the school and/or district’s public Internet site.

! I/We DO NOT GRANT permission for photo/image that includes this student to be

published on the school and or district’s public Internet site.

Student’s Name: (please print) _________________________________Student’s Grade: _____

Print name of Parent/Guardian: (print) ______________________________________________

Signature of Parent/Guardian: (sign) _______________________________________________

Relation to Student: ___________________________________________________________

Date: __________________