BYRON-BERGEN CENTRAL SCHOOL DISTRICT MEDIA DO NOT RELEASE FORM:
STUDENT INTERVIEWS, PHOTOGRAPHS AND VIDEOTAPES

Dear Parents/Guardians:

Periodically district staff writes feature articles or news stories on the students, staff, or programs within our district. It is not unusual for photographs and/or video clips of our students to accompany these articles and may be included in print newsletters, eNewsletters, website features, or social media.

For your child’s safety, minors’ full names do not accompany photographs on the website or social media. Exceptions include announcing the valedictorian/salutatorian and are not posted without specific parent/guardian permission.

If you do NOT give permission, please complete and return this form to the district office as soon as possible.

*	I do not give permission for my child, ____________________________________, to be interviewed, photographed, and/or videotaped by faculty, staff, or outside news media representatives for press or media purposes as indicated above.

CHILD'S NAME (Please Print) ______________________________________________________

GRADE LEVEL __________________________________________________________________

HOMEROOM TEACHER __________________________________________________________

PARENT/GUARDIAN NAME (PLEASE Print)_________________________________________

PARENT/GUARDIAN SIGNATURE _________________________________________________

DATE ____________