Editing previous response:

Please fix the highlighted areas below before submitting.

NYCPS Media Consent Form (Non-Profit)

Student Last Name*

Answer required for "Student Last Name"

Student First Name*

Answer required for "Student First Name"

Date of Birth*

Answer required for "Date of Birth"

Non-Profit (Third-Party) Information

Third-Party Name/Title:*

Answer required for "Third-Party Name/Title:"

By signing below, I give permission to the third party described below (the “Third Party”) to interview, photograph, and record audio and video of the student named above (the “Student”) and to publish the Student’s name, image, and likeness, including any photographs, audio recordings, and videos (the “Recordings”) for the non-profit purpose described below. I understand that the Third Party may not use the Recordings for commercial purposes.

By signing below I also release New York City Public Schools, its agents, and its employees from all claims, demands, and liabilities in connection with the rights granted above.

Parent/Guardian Last Name*

Answer required for "Parent/Guardian Last Name"

Parent/Guardian First Name*

Answer required for "Parent/Guardian First Name"

Parent/Guardian Phone Number*

Answer required for "Parent/Guardian Phone Number"

Signature of Parent/Guardian*

Signature Required

Please select one

Answer required for "Please select one"

I GIVE MY CONSENT

I DO NOT CONSENT

Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"