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Consent and Photo/Video Release Form

I, the undersigned, hereby agree to accept all conditions set forth in this consent and release.

The undersigned subject, hereby gives the Department of Elementary and Secondary Education and its Web site (www.doe.mass.edu), and /or assigns, specific permission to: copyright, publish, distribute and/or display images or video of the subject's likeness.

The undersigned, hereby releases and discharges the Massachusetts Department of Elementary and Secondary Education, and/or assigns from any and all liability by virtue of distortion, blurring, alteration, optical illusion and/or use in composite form, whether the same is intentional, or otherwise. S/he understands that images/video posted on the Internet can be viewed and downloaded by others. S/he understands that Department of Elementary and Secondary Education staff may use any process or procedure resulting in the completion of the finished product, the publication, distribution, or public display, when images of the subject are used in accordance with the usage listed below.

Usage: To display images/video on Web site and/or for the use of images in publications, media, and print collateral.

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By signing this consent and release form, the undersigned represents that s/he is of legal age in the state in which this consent and release form is executed, or whose signature is accompanied by a parent or legal guardian. The undersigned certifies that before signing this document that s/he has read it completely and understands its meaning. The undersigned hereby releases any and all future claims and rights, which s/he may have at any time, as long as the images are used in accordance to the usage above by the Massachusetts Department of Elementary and Secondary Education.

Subject Signature:
Subject Name (print):
Date:
Parent/Guardian Signature:
Parent/Guardian Name (print):
Date:
Address:


Last Updated: February 22, 2012
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