Gahanna – Jefferson Orchestra Department Publicity Release Form Re: Photographs, Audio, Videotape, Student Quotes, Internet and Broadcast This document certifies that a parent or responsible guardian has given written permission (or not given permission) for photographs, quoted statements, audio or video to be used by the Gahanna-Jefferson Orchestra Department, for the purposes of publication, promotion or achievement.
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I give my consent.
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I do not give my consent.
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___________________ _____
Print Student’s Name
School Building
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Signature of Student (if 18 or older)
Date
Grade
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Signature of Parent
or Guardian
Date
______________________________________ Printed Name of Parent or Guardian
08/2011