Atlanta Public Schools Student Media Release Opt-Out Form

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ATLANTA PUBLIC SCHOOLS STUDENT MEDIA RELEASE OPT-OUT FORM STUDENT INFORMATION Legal Last Name Legal First Name Legal Middle Name Grade Gender Birth Date Current School NOTE: If this form is not completed, it will be considered that you are allowing your student to participate in publicity-related activities and news media opportunities as described below. THE GUARDIAN MUST NOTIFY THE PRINCIPAL OF THE SCHOOL IN WRITING WITHIN 10 DAYS OF RECEIPT OF THE STUDENT HANDBOOK OR BY SEPTEMBER 1 OF THE SCHOOL YEAR. Completion of this form advises Atlanta Public Schools of your choice to not have your child’s name, image, voice or likeness appear in any form of media communication (Internet, photography, publishing, recording or videotaping) generated by Atlanta Public Schools or newsgathering organizations (news media). Additionally, you are expressing that you do not wish for your child to participate in any APS approved media or publicity interviews or discussions that may be used for promotional or newsgathering purposes unless you direct otherwise. IF YOU DO NOT WANT YOUR CHILD’S NAME, IMAGE, VOICE OR LIKENESS USED, PLEASE CHECK THE BOX AND SIGN BELOW. I do not allow district staff and/or news gathering organizations to interview, record, photograph, videotape or use my child’s likeness and name in publicity or newsgathering purposes. __________________________________________ ______________________________ Signature of Parent/Legal Guardian Date Each school is to keep this form in the student’s permanent record folder and a copy should be forwarded by school mail to the attention of the Department of Communications & Public Engagement, Center for Learning and Leadership, 130 Trinity Avenue, Atlanta, GA 30303. Atlanta Public Schools • 130 Trinity Avenue, S.W., Atlanta, Georgia 30303 • (404) 802-3500 www.atlantapublicschools.us • WABE 90.1 FM • WPBA-TV 30 • APS Cable Channel 22 .

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