Reynoldsburg City Schools

Media/Electronic Release Form

Student’s Name:  									Grade:  			

Reynoldsburg City Schools may develop, participate in, or be the subject of media and/or electronic based Internet presentations such as the Reynoldsburg City Schools home page and events that highlight various educational activities that take place during the course of the school year.  These presentations/events will include but will not be limited to the following:

•	Videotapes
•	Computer-generated presentations that may incorporate scanned photographs and video clips.
•	Computer-based productions transmitted via telecommunications
•	Photographs
•	Web pages designed at school

These media-based presentations may be used in:

•	Student recruitment presentation
•	Faculty presentations
•	The Reynoldsburg City Schools home page
•	Staff development activities
•	Media festivals
•	Public relations (newspaper articles, TV presentations, etc.)

This release is made and entered into this _______ day of _______________, 20_____ between ______________________________ (parent or guardian) and Reynoldsburg City Schools.  The parent or guardian hereby represents that he/she is the legal guardian of ____________________________ (student’s name) and has the right to sign this release granting Reynoldsburg City Schools permission to use the student’s name and/or voice, likeness and any or all of the audio or video footage in any of the Reynoldsburg City Schools or media-based productions for the above stated purpose.

X_______________________________________			________________
Parent/Guardian Signature							Date

OR

I, 					(parent/guardian) decline consent granting Reynoldsburg City Schools permission to use my child’s name, voice, or likeness in any of the circumstances as mentioned above.

_______________________________________			________________
Parent/Guardian Signature							Date

(Revised 2/12)