Form 190-4

Parental Permission Form

Permission is granted to school on behalf of my child(ren) to

(please check appropriate box):

record and tape my child(ren);
display any of my child(ren's) works; and
reproduce any of my child(ren's) work

for non-profit, educational purposes. I understand the production(s)/work(s) may be shown at educational displays during open house, inservice sessions and other school-related activities or used in a school newsletter or other school publication.

Signed this _____ day of ____________________, A.D.,_______________


Adopted: May 18, 1989
Amended: May 9, 2006
Reference: Family Law Act - Section 20 & 21