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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.

_______

I give my consent.

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I do not give my consent.

______________________________________

___________________ _____

Print Student’s Name

School Building

______________________________________

___________________

Signature of Student (if 18 or older)

Date

Grade

______________________________________

___________________

Signature of Parent

or Guardian

Date

______________________________________ Printed Name of Parent or Guardian

08/2011


Publicity Release Form 20112012