Palette Group Consent - Newark Board of Education

This form is for media interviews with students for publications and programs. Parent’s permission must be obtained prior to television, film, video or print publication interviews. This also applies to photographs and footage of students taken for the various media.

I,(Required)

First Name Last Name

the parent of(Required)

First name Last name

at(Required)

do grant my permission for my son/daughter to appear in an article/photograph/televised news program produced by

Name of individual or company(Required)

Address(Required)

Street Address City State ZIP Code

Date of Interview/Taping(Required)

Time(Required)

Statment(Required)

Date(Required)

Parent's/Guardian's Signature(Required)

Address(Required)

Street Address City State ZIP Code