Photo/Video Release Form - Student

STUDENT PHOTO, AUDIO, AND VIDEO CONSENT FORM

IMPORTANT USE LIMIT

This form records selected permissions and restrictions. It is not a blanket release of claims, assignment of ownership, indemnity, medical-information authorization, educational-record disclosure authorization, background-check consent, or consent to a third-party platform's terms.

Before use, the organization must determine which laws, school policies, contracts, safeguarding rules, and separate notices apply to the participant and program. Do not use one signature to combine legally distinct permissions.

1. ORGANIZATION AND PROGRAM

2. PARTICIPANT

3. PERSON GIVING PERMISSION

☐ Adult participant

☐ Parent

☐ Court-appointed or otherwise authorized guardian

☐ Other authorized person: [________________________________]

The organization must confirm who may consent for this participant. A checked box does not create legal authority.

4. CAPTURE PERMISSIONS

Select each type the organization may create. An unchecked type is not authorized by this form.

☐ Still photographs

☐ Video without recorded audio

☐ Video with recorded audio

☐ Audio-only recording

☐ Livestream visible only to an approved closed audience

☐ Livestream available to the public

☐ Participant-created content submitted to the organization

☐ No recording or image capture for public or promotional use

Specific event, class, project, or location covered:

[____________________________________________________________]

Excluded event, class, project, or location:

[____________________________________________________________]

5. USE PERMISSIONS

Select each permitted use. Capture permission does not authorize an unchecked use.

Program and Internal Uses

☐ Private program recap shared with enrolled participants or families

☐ Internal staff training

☐ Internal historical archive with controlled access

☐ Participant portfolio or progress record provided to the participant or family

Organization-Controlled Public Uses

☐ Organization website

☐ Organization-managed social-media account

☐ Organization email newsletter

☐ Printed brochure, poster, or annual report

☐ Organization presentation or event display

☐ Paid advertising controlled by the organization

External Uses

☐ News media identified here: [________________________________]

☐ Sponsor or partner identified here: [________________________________]

☐ Conference or publication identified here: [________________________________]

☐ No external sharing

No permission is given to an unnamed sponsor, partner, publisher, media outlet, or other third party unless separately approved.

6. IDENTIFICATION AND CONTEXT

Name and Identifying Information

☐ No name or identifying information

☐ Preferred or first name only

☐ First name and last initial

☐ Full name

☐ Program, team, class, or grade may be identified

☐ School, facility, or general location may be identified

☐ Exact location, schedule, or contact information may not be disclosed

Sensitive Context Restrictions

Do not use media from or in connection with the following unless separately reviewed and authorized:

☐ Health, counseling, disability, or accommodation services

☐ Discipline, investigation, or safety incident

☐ Changing, sleeping, bathing, restroom, or similar private setting

☐ Location or schedule information that could create a safety risk

☐ Religious or cultural activity identified here: [________________________________]

☐ Other restricted context: [________________________________]

7. EDITING AND PRESENTATION STANDARDS

The organization agrees to use authorized media only within the selections above and to apply these controls:

☐ No misleading change to the participant's words or actions

☐ No use suggesting an endorsement the participant did not make

☐ No use in a discriminatory, sexualized, humiliating, or unsafe context

☐ No synthetic alteration of the participant's face or voice without separate written permission

☐ Captions and identifying text will be checked for accuracy

☐ Access to original files will be limited to authorized personnel

Additional standards:

[____________________________________________________________]

8. TERM AND WITHDRAWAL PROCESS

Consent begins on: [__/__/____]

Consent ends on:

☐ [__/__/____]

☐ End of the identified program or event

☐ Another stated event: [________________________________]

How to request a change or withdrawal:

After receiving a valid request, the organization will record it and apply it to new organization-controlled uses after the stated processing period. Previously printed, distributed, archived, reposted, or third-party-controlled copies may require separate review and may not be fully retrievable. Applicable law, contract, or policy may require a different result.

9. COMPENSATION AND OWNERSHIP

Compensation arrangement:

☐ No compensation is offered for the selected uses.

☐ Compensation or benefit is described in a separate agreement: [________________________________]

This form does not transfer the participant's ownership rights or make a blanket assignment of every right in the media. Any ownership, license, participant-created-content, or commercial-production term must be stated in a separate counsel-reviewed agreement or a clearly identified addendum.

10. CONSENT SELECTION

Choose one:

☐ SELECTED CONSENT: Permission is given only for the checked capture types, uses, identification choices, term, and restrictions above.

☐ NO PUBLIC OR PROMOTIONAL CONSENT: The organization may not use this form as permission for public or promotional capture or use.

☐ REPLACEMENT FORM: This form replaces the participant's prior form dated [__/__/____], subject to the processing and prior-use limits stated above.

Unchecked items are not authorized by this form.

11. ACKNOWLEDGMENTS

☐ I reviewed the selected capture types and uses.

☐ I had an opportunity to ask questions.

☐ I received or can obtain a copy of this completed form.

☐ I understand how to request a change or withdrawal.

☐ I understand that separate legal or policy permissions may be required for some records, services, platforms, or activities.

☐ No organization representative promised a use or outcome not written here.

12. SIGNATURES

Person Giving Permission

Signature: ________________________________________

Printed name: [________________________________]

Relationship or authority: [________________________________]

Date: [__/__/____]

Participant Acknowledgment

Use when appropriate to the participant's age, understanding, program, and governing requirements.

Participant signature: ________________________________________

Printed name: [________________________________]

Date: [__/__/____]

Participant preference or concern:

[____________________________________________________________]

Organization Representative

Signature: ________________________________________

Printed name and title: [________________________________]

Date received: [__/__/____]

13. ORGANIZATION PROCESSING RECORD

14. FINAL ADAPTATION CHECKLIST

☐ Participant age and signer authority reviewed

☐ Public, private, livestream, press, sponsor, and paid-advertising uses separated

☐ Name and location permissions separated from image permission

☐ Sensitive contexts excluded or separately approved

☐ Withdrawal process matches actual operational capability

☐ Storage, access, retention, vendor, and security practices reviewed

☐ Separate records or privacy authorization added if required

☐ No blanket indemnity, ownership assignment, or release of unrelated claims included

SOURCES AND REFERENCES

No jurisdiction-specific authority is cited because this version records operational preferences and selected permission only. Counsel must add any current official authority, notice, or separate authorization required for the participant, organization, program, jurisdiction, and intended use.

END OF CONSENT FORM