Florence School District One

Student Internet Publications

                           Parental Authorization Form

Dear Parent/Guardian:

Your child’s photo, first and/or last name, and/or original work may be considered for publication on the school’s web at http://www.fsd1.org/(westflorence) according to the permission you authorize below.  Please complete and return the following consent form to the school your child attends.   All information is kept private and confidential and will not be placed in any publication. Please be assured that no personal information (schedule, age, address, phone #, etc., will be on any web site.

Student’s name ______________________________________ Grade ________

Homeroom teacher’s name___________________ Age _______

School_______________________________________________________

Please check all that apply:

I give permission for my child’s photo to be used without the child’s name on his/her school’s or the district’s web page.

I give permission for my child’s full name to be used without a photo of him/her on his/her school’s or the district’s web page.

I give permission for my child’s first name only to be used without a photo of him/her on his/her school’s or the district’s web page.

         I give permission for my child’s first and last name to be used with a photo of him/her on     

         his/her school’s or the district’s web page.

I give permission for my child’s original Artwork (drawing, painting, writing, graphic art etc…) to be used without the child’s name on his/her school’s or the district’s web page

I give permission for my child’s original Artwork (drawing, painting, writing, graphic art etc…) to be used with child’s first name only on his/her school’s or the district’s web page.

Parent’s signature:  _____________________________________________

To be completed by the student for publication of original work:

All work submitted for publication on my school web page will be an original work(s) created by me.

Signature of student ___________________________________________