Video Release Form - Curriculum Frameworks and Instructional Resources (CA Dept of Education)

Sample Video Release Form (CDE)

T07-142 English, Arial Font

Page 1 of 1

[For consideration by local educational agencies (LEAs), the California Department of Education makes available two different templates for Video Release Permission:

T07-141and T07-142. An LEA should review both templates and confer with legal counsel to determine which of the two forms is preferred

for particular situations and local needs.]

PHOTOGRAPHIC and/or VIDEO RELEASE FORM

I hereby release the [ADD NAME OF DISTRICT HERE] to use any and all pictures of [ADD NAME OF STUDENT HERE] taken on this date: ____________

I understand that such photographs will be used for [ADD NAME OF DISTRICT HERE] publications or exhibits.

Date: _____________

Signature of participant: _______________________________________

Signature of parent/guardian if participant is under the age of 18;

_______________________________________

Mailing address: _____________________________________________

Street Address

_____________________________________________

City State Zip code

_____________________________________________

Telephone number e-mail address

© California Department of Education, April 30, 2008