Release Form for Media

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					                                 Star Country 96.7
                               PO Box 911, Lewistown PA 17044
                                        717-242-1493

                            Student Media Release Form

Dear Parent:

We would like to include your child’s full name and picture on the Star Country 96.7 website
to recognize them for nominating their teacher for our Teacher of the Week promotion. This
means that your child’s picture, name and school will be on our website on the internet. The Star
Country web site is at the following address: http://www.star967.com

Please complete and return the following to school indicating your wishes regarding the
publication of your child’s photo and name on the Star Country web site.

Date: ________________

Student Name __________________________________________

School: _______________________________________

Please check

             I do give my permission for my child’s photo and name to be published on the Star
             Country website.

             I do not want my child’s photo and name to be published on the Star Country web
             site.




________________________________________________________                   _________________
                 Parent/Guardian Signature                                        Date


Please contact me if you have any questions or concerns.

Sincerely,

Mandy Seitz
Promotion Director
Star Country 96.7, WCHX 105.5, WKVA 920 AM
717-242-1493

				
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Description: Release Form for Media document sample