Student Media Consent and Release Form

I am a Music Intern in the University of Connecticuts teacher education program currently

working with your child(ren) at Batchelder School. I am writing to inform you that as part of
my Inquiry Project, I am creating a documentary about how participating in music groups
(like our recently created band class) can help students grow. With your permission, your
child may be featured in parts of the documentary including student interviews, candid
rehearsal videos, music, and pictures recorded during music class and band rehearsals.
I, as the parent or guardian of __________________________________________, hereby give
Ms. Rainwater permission to print, photograph, and record my child for use in audio, video,
film, or any other electronic, digital and printed media.

This is with the understanding that neither Ms. Rainwater nor any representative of the school will
reproduce said photograph, interview, or likeness for any commercial value or receive monetary gain
for use of any reproduction/broadcast of said photograph or likeness. I am also fully aware that I will
not receive monetary compensation for my childs participation.

I certify that I have read the Media Consent and Release Liability statement and fully
understand its terms and conditions.

You do not have to agree to your child participating in the video recording if you do not
want to. He or she will still be able to participate in music class, and band rehearsals;
however, we will situate the camera so that he or she does not appear in the documentary.

Please let us know if you have any concerns or questions about the appearance of your child
in this videotape so that we may be sure to address them. If you have further questions
about this project, please contact Ms. Rainwater by email at: allison.rainwater@uconn.edu

Please return this form to school by March 1 st . Failure to do so will constitute

disapproval of the above requests, and will result in the student being excluded from the
documentary.

Please Print Name of Child(ren): _________________________________________________________

Grade(s): ___________________________

Please Print Name of Parent or Guardian: ________________________________________________

Relationship to Child: ____________________________________________

Signature of Parent or Guardian: ________________________________________________________

Date: _____________________________