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Media Consent Form

Office of Communications and Media Relations

52 Chambers Street, New York, NY 10007

Tel: 212.374.5141 Fax: 212.374.5584

CONSENT TO PHOTOGRAPH, FILM, OR VIDEOTAPE A STUDENT FOR NON-PROFIT USE

(e.g. educational, public service, or health awareness purposes)

School: PS 181Q, The Brookfield School

Please complete the form below. Required fields marked with an asterisk *

Student's Full Name*

Answer Required

I hereby consent to the participation in interviews, the use of quotes, and the taking of photographs, movies or videotapes of the student named above by PS 181Q, The Brookfield School.

I also grant PS 181Q, The Brookfield School the right to edit, use, and reuse said products for nonprofit purposes including use in print, on the internet, and all other forms of media. I also hereby release the New York City Department of Education and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above.

Parent/Guardian Full Name*

Answer Required

Student's Class*

Answer Required

Date Consent Given*

Answer Required

If you would like to submit images of your child from an event you may upload images, media, and/or files you would like us to add to the website/social media (no guarantees)

Answer Required

Choose a file or drag it here.

What event are these images/videos from (ex. Kindergarten Zoo Field Trip, Basketball Game, PTA Fundraiser, etc...)

Answer Required