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Plano Independent School District
Publications, Video, Internet Consent and Release Agreement 
 
Individuals are occasionally asked to be a part of school and/or district publicity, publications and/or public relations activities. In order to guarantee your privacy and ensure your agreement for your to participation, the district asks that you sign this  form. 
The form referenced below indicates approval for your name, work, email address, telephone number, voice/ verbal statements, portraits (video or still) , to appear in school publicity, district publications, videos or on district web sites.  For example, pictures and articles about school activities may appear in local newspapers, district web sites, or district publications. These pictures and articles may or may not personally identify you. The pictures and or videos may be used by the district in subsequent years. 
AGREEMENT
I release to Plano ISD my name, work, email address, telephone number,
voice/ verbal statements, portraits (video or still) and consent to their use by PISD.
x
Plano ISD agrees that your name, work, email address, telephone number, voice/ verbal statements, portraits, 
or video shall only be used for public relations, public information, school or district promotion, publicity, and instruction. 
.
I understand and agree that: 
  •  No monetary consideration shall be paid; 
  •  Consent and release have been given without coercion or duress; 
  •  This agreement is binding upon heirs and/or future legal representatives; 
  •  The  name, work, email address, telephone number, voice/ verbal statements, portraits (video or still) may be used in  subsequent years. 
.
Effective Date of Agreement : __ __ /__ __ / __ __ __ __ 
If you wish to rescind this agreement you may do so at any time with written notice.

Name: ____________________________________________________________
                                          ( Print Name as you wish it used ) 

Written Signature: _____________________________________________________________________________
                                    ( If at least 18 years old ) 

Please mark X in the appropriate blank space.
___  My email address may be used on the web site.       ___  My email address is for reference only .
___  My telephone number may be used on the web site.  ___  My telephone number is for reference only.

PISD staff names, telephone numbers, and email addresses are public record. Please fill in your information.

Email Address :  (Please print) _____________________________________________________

Telephone Number :  Area Code ( __ __ __ )  __ __ __ - __ __ __    Extension (  __ __ __ __ __  )
 
.PISD has no control of media use of  name, work, email address, telephone number, voice/ verbal statements, portraits (video or still) which are taken without permission 10/01/99 . *This form modified to include information needed for Mathews Elementary School Web Site.  mathews@pisd.edu