Medication/Treatment/Special Diet Orders

STUDENT PERMISSIONS SHEET

STUDENT NAME:

Please read the following permission information carefully. Mark the appropriate box then sign and date the form.

This form will be placed in your child’s educational file. Your permission will be maintained for as long as your child attends The Maryland School for the Blind (MSB) or until such time as you revoke your permission. You may withdraw your consent at any time. Should you choose to withdraw permission, you must do so by notifying MSB in writing, and understand that your withdrawal of any permission is not retroactive. You may request a copy of this document at any time.

PUBLIC RELATIONS – I permit MSB to use my child’s name, image, likeness or voice in internal and external school related print publications, marketing and fundraising materials, television or news broadcasts, films, videos, audio recordings, still photographs, websites, and for the purpose of trainings and evaluations. I also agree to my child being interviewed, photographed and/or videotaped by representatives of media outlets for news stories about the school and/or its students, employees, programs and special events. Such stories may be printed in local, state or national publications; broadcast on local, state or national news programs; posted on websites; or distributed to media outlets. I also grant permission for my child to be interviewed, photographed and/or videotaped by representatives of the Maryland State Department of Education (MSDE) for educational stories about MSB and/or its students, employees, programs and special events. Such stories may be printed in MSDE publications, broadcast on local, state or national news programs, posted on websites or distributed to media outlets.

I release MSB from any and all claims and demands arising out of or in connection with the use of materials, including but not limited to any claims for invasion of privacy, appropriation of name or likeness, or right of publicity. I hereby waive any right that I may have to inspect or approve the finished product that may be used or the use to which it may be applied. Without limiting the other rights granted in this agreement, I agree that MSB may use my student’s name, image or likeness, statements, and voice reproductions without further parental/guardian approval. I understand that some events are open to the general public and may be photographed, videotaped and/or viewed by the general public. MSB is not liable for the usage of public photos or videos.

Permission Granted Permission NOT Granted Page 2

PARENT/STUDENT DIRECTORY - The parent/student directory was created by MSB at the request of parents of students attending MSB. The directory will be updated each year to increase your ability to communicate with each other. The directory will include the following information: your child’s name and date of birth; parent/guardian name; address; phone numbers; and e-mail. A copy of the directory will only be provided to parent/guardians of MSB students. Participation in the directory is voluntary. However, IF YOU DO NOT WISH your information to be listed in the directory you must notify MSB in writing before September 1 ST of the current school year.

Permission Granted Permission NOT Granted

OFF-CAMPUS ACTIVITIES - Throughout the school year students have numerous on-going community integration activities which take them off-campus. Many times these activities are related to IEP goals that the student is working on or are activities that are important to a well-rounded program. Sometimes they are of an educational nature and sometimes of a recreational nature. These may include but are not limited to off-campus work, grocery shopping, Laundromat, local bowling alley, movie theatre, restaurant, mall trip, etc., and would be within a 10 mile radius of the school. A school-approved driver will transport your child to such activities in an MSB vehicle. We request permission from you for your child to participate in off-campus activities which MSB approves.

Permission Granted Permission NOT Granted

Field trips such as, but not limited to, rock-climbing, snow tubing, amusement parks, therapeutic riding, snow skiing, etc., are not included in the above permission but require a separate permission/waiver to be signed by the parent/guardian of each student attending the trip. These forms are sent to the parent/guardian in advance of each scheduled trip.

______Parent/Guardian Signature Date

Revised: 4/11/14:dm