Academic Derby Television And

Academic Derby Television and

Streaming Release Form 2016-2017 revised 7/7/16

My child______,

a student at______,

has my permission to participate in Academic Derby for the

2016-2017 School year. I understand that the matches will be taped at the Onslow County Schools Video Production Studio located at Southwest High School and broadcast on Time Warner and Charter Cable local government channels as well as available on Onslow County Schools YouTube Channel, Facebook and Twitter feeds. Derby footage may also appear in other promotional and information productions produced by the OCS Community Affairs Multimedia Department.

______

Parent / Guardian Signature Date

NOTE: No child will be allowed to participate in an Academic Derby Match until this form has been signed and returned to the administrative staff of the Academic Derby program.

Parents / Guardians Names -- please print

Mailing address:

City: Zip: Phone: