MONTGOMERY COUNTY PUBLIC SCHOOLS
850 Hungerford Drive
Rockville, Maryland 20850
CONSENT AND RELEASE for 2015-2016 School Year
General Release
I hereby consent to the nonprofit use of my child’s likeness and/or voice by the Montgomery
County Public Schools and its assignees for all purposes of education, instruction, or public
information with or without use of my name.
Yes
No
Internet Release
I hereby give my consent to Montgomery County Public Schools to use my child’s name,
picture, outstanding schoolwork, and information about awards, honors, and achievements on
Internet web pages created by or under the auspices of MCPS. Home address and telephone
numbers will not be used.
Yes
No
Limited Release
I hereby give my consent to Montgomery County Public Schools to publish my child’s work, but
not name or photo, in publications or on Internet web pages created by or under the auspices of
MCPS. If you checked ‘NO’ on either General Release or Internet release above, please check
yes or no below.
Yes
No
Name of Student:
(Please Print First and Last Name of Student)
Signature of Parent:
Date:
Printed Name of Parent:
PLEASE RETURN THIS FORM TO CABIN JOHN MIDDLE SCHOOL OR IT IS
ASSUMED THAT IT IS OK TO FILM, PHOTOGRAPH, RECORD AND INCLUDE
YOUR CHILD’S LIKENESS ON THE WEBSITE AND YEARBOOK.