Download Permission to Use Student Image - ArtsEdge

Permission to Use Student Image
Name Of Arts Company/Organisation/Practitioner To Be Inserted
Full Name of Student
Teacher and School
School Year Level (Yr K-12)
Full Name of Parent/Legal Guardian
Address
Telephone Number(s)
Email Address
I …………………………………………………………… (full name) being the parent or legal guardian of …………………………………………(full
name) hereby give permission to:
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
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Arts Organisation/Practitioner working with school as identified above
ArtsEdge (strategic partnership of DCA/DOE)
Department of Education (DoE)
Department of Culture and the Arts (DCA)
to use (tick as appropriate):
Yes
No
Student Name
School Name
School Address
Image/Photograph
School Year Level (Yr K-12)
in:


materials developed for educational purposes and which may be available in print, on a CD-ROM, in audio or
visual form, through the Internet/World Wide Web on the websites of the practitioners and/or organisations
and/or authorities listed above and/or any other relevant teacher resource Website; and
materials developed for promotional and archival purposes and which may be available in print, on a CD-ROM,
in audio or visual form, through the Internet/World Wide Web of the websites of the practitioners and/or
organisations and/or authorities listed above and/or any other relevant teacher resource Website.
for the period being (tick as appropriate):
Yes
This school year only
Enduring/Ongoing
My child’s details as they are to appear as outlined above are as follows:
Name of student (where applicable):
Name of student’s school (where applicable):
School’s address (where applicable):
School contact details (where applicable):
Phone:
Fax:
Email:
I understand that:
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Publication of my child’s image in print, on a CD-ROM, in audio or visual form or through the Internet/World
Wide Web may enable viewers/readers to identify my child;
My child’s images may appear in educational and/or promotional/archival materials as identified previously;
Not every image for which permission is gained will ultimately be used by the practitioners and/or
organisations and/or authorities listed above, and therefore there is no guarantee that all of the details
supplied above will be published.
IMPORTANT - PLEASE NOTE:
The Internet/World Wide Web may be accessed by any person worldwide.
I understand that if my child’s personal information (as identified by me above) is published on the
Internet/World Wide Web then it will be accessible to users from all over the world, that his/her
information can be searched for using an identifier such as their name, and that my child’s information
can be copied and used by any other person using the Internet/World Wide Web.
Most importantly, I understand that once my child’s personal information has been published on the
Internet/World Wide Web, the practitioners and/or organisations and/or authorities identified above have
no control over its subsequent use and disclosure.
Please note, if you wish to view the websites of the organisations/authorities listed above please see:
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Arts Organisation/Practitioner details inserted as appropriate

ArtsEdge
www.artsedge.dca.wa.gov.au

DOE
www.det.wa.edu.au

DCA
www.dca.wa.gov.au
I understand that I can withdraw this permission at any time by contacting the organisations/authorities listed
above in writing; however this cannot be retrospective (eg where materials have been produced and
disseminated).
Signature of Parent/Legal Guardian:
Home Phone:
Email:
Date:
Mobile Phone: