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Dear Parent/Guardian:
We would like to notify you of the Grayson County High School website. This site may be viewed at
http://ims.grayson.k12.va.us. Independence Middle School would like to acknowledge student accomplishments by
posting pictures to the site. Please complete the information below and return this form to your first period teacher
or advisor by August 27, 2015.
Grayson County Public Schools
Permission and Release Form
School Year: 2017-2018
School:
Independence Middle School
Student Name: __________________________________________
Student Grade Level: _____________________
The purpose of this form is to seek permission for your student to be interviewed, photographed, and/or videotaped
by the media (radio or television stations, and newspaper reporters). In addition, Grayson County Public Schools seek
permission for your student’s photograph or name to be used on the Grayson County Public School’s website or in its
publications.
Grayson County Public Schools will not release personal student information to the media. Personal information
includes; but is not limited to address, telephone number, medical history, academic records and discipline records.
Please check one of the following:
________
YES,
I
give
permission for my student to be interviewed and/or photographed by the media while
participating in a school-sponsored event. This includes media and achievement recognition of my
student by name, age and grade level. This also includes my student’s photograph or name to be
used on the Grayson County Public School’s website, including but not limited to Independence
Middle School, or in its publications.
________
NO
, I
do n t
give
permission for my student to be interviewed and/or photographed by the media
while participating in a school-sponsored event. This includes media and achievement recognition of
my student by name, age and grade level. This also includes my student’s photograph or name to be
used on the Grayson County Public School’s website, including but not limited to Independence
Middle School, or in its publications.
Parent/Guardian Signature
: __________________________________________
Date: ___________________
Parent/Guardian Name:
(Please Print)