Kellogg Middle School

Media Permission Form

Throughout the year, Kellogg students are often highlighted in newspaper and magazine articles or television, radio, and video productions. To avoid the need to get parent permission each time one of these opportunities arises, we are asking that only parents who DO NOT want their student’s photo and/or name to be used in these situations to complete this form and return it to the main office. We will assume it is OK to use any student’s name and/or photo if we do not receive this form back.

I do not want my student’s name or photo used in any publication or media production.

Student’s Name ____________________________________________

Grade ___________________

Parent’s Name _____________________________________________

Parent’s Signature __________________________________________

Date _____________________