Request Permission of Copyrighted Material Form

Crescent View Middle School

11150 S. 300 E.
Sandy, Utah 84070
Dear ____________________________________________,
I am a student at Crescent View Middle School and would like to receive your
permission to use, without charge, the following material for educational purposes.
Thank you for your time in this matter.
Student Name ________________________ signature ______________________________
Parent Name ________________________ signature ______________________________
Type (Illustration, music, video)

Project

Permission Granted

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yes/ no Date ________

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yes/ no Date ________

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yes/ no Date ________

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yes/ no Date ________

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yes/ no Date ________

Copyright owner or agent ________________________ signature ______________________________