Media Release Permission Slip

Recording of various school and classroom activities through the use of photography, audio, and video equipment is done by Lakeview Public Schools throughout the year. The recording might circulate to other students or classrooms, be used in district publications, on the district website/internet, or be shown on local TV access cable.

If parents/guardians or students 18 years old or older approve of the use of photography, audio, or video transmission of your child/themselves, please fill in this form and return it within five (5) days of receipt, to your school principal. For further information, you may contact Debbie DePape at

(586) 445-4000, Ext. 2501.

Lakeview Public Schools

RELEASE PERMISSION

2014/2015 School Year

You may use a picture of my child without identifying by name.
You may use a picture of my child using a first name only.
You may use a picture of my child including my child’s first/last name.
I do not wish to have my child photographed or video recorded during the
2014/2015 school year.

IMPORTANT — IF YOU CHECKED ONE OF THE FIRST THREE (3) STATEMENTS ABOVE, YOU MUST ALSO CHECK ONE OF THE STATEMENTS LISTED BELOW.

I understand I am giving my permission for the district to use the information referenced in the above checked statements in all district publications, INCLUDING use on the district website and/or the internet and TV access cable.

I understand I am giving my permission for the district to use the information referenced in the above checked statements in all district publications, EXCLUDING use on the district website and/or the internet and TV access cable.

Child’s Name
Please SelectArdmore ElementaryGreenwood ElementaryHarmon ElementaryPrinceton ElementaryJefferson Middle SchoolLakeview High SchoolWheat Early Childhood Center / Please SelectPreschool - ECSEPreschool - GSRPPreschool - 3 Year OldPreschool - 4 Year OldKindergarten123456789101112
School Attending / Grade
Signature of Parent/Guardian / Date

Nondiscrimination and Access to Equal Education Opportunity : It is the policy of the Board that no student in this District shall, on the basis of race, color, religion, national origin or ancestry, age, gender, marital status, sexual orientation, disability, height, weight, and/or any other legally protected characteristic, be discriminated against, excluded from participation in, denied the benefits of, or otherwise be subjected to discrimination in its programs and/or activities. Any person believing they have been discriminated against may bring a complaint to the local civil rights coordinator: Assistant Superintendent, 27575 Harper Avenue, St Clair Shores MI 48081, 586-445-4000 x 2503