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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: 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: 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: 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: