military release and photo release forms by Fp05N61

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									                                LANSINGBURGH HIGH SCHOOL
                                         320 Seventh Avenue
                                        Troy, New York 12182
                                           (518) 233-6806

               PARENT CONSENT FORM FOR RELEASE OF STUDENT INFORMATION
                  TO MILITARY RECRUITERS, PROSPECTIVE EMPLOYERS, AND
                             POST-SECONDARY INSTITUTIONS

Lansingburgh High School Student:
Military recruiters, prospective employers, colleges and other post-secondary institutions may request
that the school provide them with the names, addresses and telephone numbers of enrolled high school
students. Parents may choose to either participate or not participate in this program. Students who are
18 years old or older have the right to decide whether or not to participate in this program.

Please complete this form and return it to the Lansingburgh High School. In the event this form is not
completed and returned to the school, all requests for information will be honored.

Parents:
Check to indicate whether you wish to have your child’s name, address and telephone number disclosed
to the groups that may request it.

_____ DO NOT disclose my child’s name, address and telephone number to the entities checked below
without my prior written permission:

        _____ US Military Recruiters (Army, Navy, Air Force, Marines, etc.)
        _____ Colleges, Universities and other educational institutions
        _____ Prospective Employers

Print Name of Student ___________________________ Grade _______ Date _____________________
Print Name of Parent_________________________ Signature of Parent __________________________


Students who are 18 years old or older:
Check to indicate whether you wish to have your name, address and telephone number disclosed to the
groups that may request it.

_____ DO NOT disclose my name, address and telephone number to the entities checked below
without my prior written permission:
       _____ US Military Recruiters (Army, Navy, Air Force, Marines, etc.)
       _____ Colleges, Universities and other educational institutions
       _____ Prospective Employers

Print Name of Student ___________________________ Grade _______ Date _____________________
Signature of Student _____________________________
                      LANSINGBURGH CENTRAL SCHOOL DISTRICT

                     OPT OUT PERMISSION TO USE STUDENT PHOTOGRAPH


I DO NOT grant permission to Lansingburgh Central School District to use the photograph,

Photographic image, name, audio recording and/or video recording of

___________________________________, ___________, ____________ for purposes of
Student’s Name                       Grade        School

General publicity and/or student recruitment, in any medium whatsoever, including but not

limited to publications, public relations, promotions, publicity and advertising.



_____________________________________________               __________________________
Parent/Guardian Signature                                    Date


_____________________________________________ __________________________
Student Signature                             Date

_________________________
Telephone

								
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