Middlesex Elementary School

NCPS employs various media for educational & promotional purposes: photos, videos, audio recordings, & written narratives of students. These may be featured on school & district websites, social media, printed/digital materials, & shared with external organizations or the media & serve as the permission until the student changes schools. This form allows guardians to grant permission for their child's image to be used. If you don't opt-in it will be assumed an Opt-Out.

1) Your Child's School: Required*

Please select your child's school. If their school is not listed - you are in the wrong form.

Middlesex Elem

Not Listed

2) Child's Student ID Required*

Please write out your child's student ID #

3) Your Child's Name: Required*

4) Your Child's Grade: Required*

Pre-K

5) Option 1 - OPT-IN - YES Required*

I hereby grant Nash County Public Schools permission to capture use photographs, videos, audio, and written narratives of my child during instructional school activities throughout the current school year for display, publication, or release to external organizations in print, video, and/or digital media.

OPT-IN - YES

Confirmation of the Above Choice

6) Best Phone Number Required*

7) Parent/Guardian Name Required*

8) Your Email/Best Email Required*

9) Signature Fields Required*

By signing below, you acknowledge that you have read and understood the terms of this consent form. This consent covers various media types, including but not limited to photographs, videos, audio recordings, and written narratives. It pertains to school-related activities during the current school year.

Signature

I understand that my typed signature is the legal equivalent of my handwritten signature on this document.

10) Date & Time Required*

11) Electronic Consent Required*

You have read this form in full and privacy policy and give consent.

Yes, I consent.

No, I do not consent.

Middlesex Elementary School
Forms

Forms

Middlesex Elementary- Model Release Form - updated in effect Jan. 1, 2024

1 forms were found.

Find Us

Middlesex Elementary School13081 West Hanes AvenueMiddlesex, NC 27557Phone: (252) 462-2815Fax: (252) 235-5216

Stay Connected

The Nash County Public Schools System does not discriminate against any person on the basis of race, sex, age, color, religion, national origin, citizenship status. political affiliation, or disability in any of its educational or employment programs or activities.

Accessibility | Privacy Policy | Signs of Abuse Resources | NCPS Copyright Notice