Parents (including legal guardians) are required to provide written permission to their child's school if they wish to:
1) allow their child to participate in school activities and the School District to publish the student's name, school name, grade level,
photograph, video image, art work, writing, etc. in annual yearbooks, graduation programs, web sites, school newspapers, approved
news gatherings, releases and articles, etc.
AND
2) allow publication to the public of certain specified information (such as honors received) related to their child.
PBSD 1941 (Rev. 8/5/2016) ORIGINAL - School COPY - Parent/Student
DIRECTIONS: If this is a blanket consent for all student publications throughout the school year, the parent will check the appropriate box and
provide the school year. If a one-time release and consent for a special project is required, the parent will check the special release box and list
below the name of the special project publication. The parent will sign and return to the student's school.
Signature of Parent/Guardian or Emancipated Student
(including if age 18 or over - proof of age required)
Date
I give permission for the consent request indicated above.
I do not give permission for the consent request indicated above.
The School District of Palm Beach County shall have the right to sell, duplicate, reproduce or make other use of such rights transferred as The
School District of Palm Beach County so desires. This agreement is given with free knowledge of the rights transferred to the School District of
Palm Beach County. This agreement is made without restrictions or time limits.
I also understand the production, publication, presentation or materials may be submitted for classwork, for open broadcast by Instructional
Television (ITV), The Education Network (TEN), a film festival or contest or any other display according to the broadcast/ publication rules of
the appropriate trade.
I hereby give permission for the school or District to use my child's photograph, video image, writing, voice recording, name, grade level,
school name, etc. in the special production named above.
special release and consent for the student information publication listed below:
blanket release and consent for all student information publications for school year
I hereby give permission for the school or District to use my child's photograph, video image, writing, voice recording, name, grade level,
school name, participation in officially recognized activities and sport, weight and height of members of athletic teams, dates of attendance,
diplomas and awards received, date and place of birth, and most recent previous school attended, in annual yearbooks, graduation
programs, playbills, school productions, web sites, social media sites, etc. and/or similar school or District sponsored publications or in
school or District approved news media interviews, releases, articles, and photographs. I also provide permission for the release by the
school or District to the media and governmental entities of my child's name, grade, school name and honors my child has received for
public announcement of recognition of my student's accomplishments. I understand that without checking the permission box my child's
name and photograph cannot and will not be included in any publications or presentation, including a school yearbook.
Parent/Guardian Name
Contact Phone Number
School Name
Student Name (first, middle initial, last)
Student ID #
School Contact
TYPE OF CONSENT (check one only)
Grade
THE SCHOOL DISTRICT OF PALM BEACH COUNTY
Release and Consent for Student Information
Publication
