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: ___________________________________________________________