Hazlet Township Public Schools

Parental/Guardian Consent Form

We are sending you this parental consent form to both inform you and to request your permission for your child’s photo/image and personally identifiable information to be published on the district and/or schools 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 information includes student names, photo or image, residential address, 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 this student’s photo/image and name to be published on the school and/or district’s public internet site.

Student’s Name (please print) ________________________________________ Grade ________

Name of Parent/Guardian (print) _____________________________________________________

Signature of Parent/Guardian (sign) ___________________________________________________

Relationship to student ______________________________________________ Date __________