Consent form: Parent/Guardian consent to the use of their information in SelfDesign communications

Email *

Consent

I consent to SelfDesign's collection and use of my child's first name, image, video, expressions or commentary for the purposes of creating newsletters, advertisements, handouts, flyers, brochures, websites, blogs, social media entries, community reports, slideshows, pictures, presentations or other similar communications (the "Informational Materials") for the purpose of demonstrating SelfDesign's programs and activities to current and potential SelfDesign Learning Community learners, families, contractors and affiliates along with interested stakeholders and the public.

(All correspondence and reporting between a family and their educator(s) including: Observing for Learning communications, course assignments, annual reviews, seasonal reviews, and emails will not be shared unless the family provides explicit additional permission for that.)

I understand and agree that my child's information may be disclosed as stated above. *

Yes, I provide my consent
No, I do not consent

Checkboxes *

I understand that by NOT providing consent to share personal information, it is my and my child’s responsibility to ensure we have taken the steps necessary to limit exposure and ask for facilitator assistance BEFORE the event is live online and/or recorded.

Family Info

Parent/Guardian Name *

First

Last

I Grade Grade

First Learner's Name *

First

Last

First Learner's Grade *

Second Learner's Name

First

Last

Second Learner's Grade

Third Learner's Name

First

Last

Third Learner's Grade