SBSD

South Burlington School District

Student Privacy Form, 2003/2004

Student Name: ________________________ Parent / Guardian Name: _____________________

Teacher (if known): ____________________ Grade (Please Circle): K 1 2 3 4 5 6 7 8 9 10 11 12

School (Please circle): Central Chamberlin Orchard Tuttle Middle South Burlington High

Introduction: Students are making increasing use of various technologies as powerful learning tools. Key benefits of such activities include opportunities to share work with and interact with other students and the world at large. Such activities are not entirely without risk. Media and technology provide students with access to people and information beyond the South Burlington School community and enable others to view student work and interact with students in the South Burlington schools. Student work can be shared in a variety of ways, including newsletters or newspapers, radio or TV programs, web pages, electronic mail, compilations of student work on a class CD, etc. It is important for parents and students to consider the level of exposure for the students’ work.

Student Privacy Guidelines: A paramount goal of the South Burlington School District is to ensure the safety and privacy of our community of learners. To help achieve this goal, publication of student information on the Internet and sharing of student information via print media, electronic mail, video, and other technologies is restricted. Student information and student work will not be published or shared unless permission is obtained. Permission is granted only for projects or activities that take place in a specific school year. Students must submit an updated permission form each year. No personal information, such as home or mailing address and phone number, except as listed below, will be published or shared.

Parent Section: I understand that my child may engage in classroom projects and activities that enable others to view or listen to him or her, view his or her work, and/or to interact with him or her. In order for my child to participate in such projects and activities, I understand that this permission form must be completed, signed, and on file at my child’s school and that lack of a permission form will be regarded as “permission denied.” I understand that, where possible, appropriate alternative activities will be provided as substitutes when permission is not given. Further, I understand that, as part of classroom activities,

The items checked “Yes” below may be published or shared as part of this school year’s projects or activities. Items checked “No” may not be published or shared.

Student’s Initials ‰Yes ‰No Recognizable Picture of Student ‰Yes ‰No Student’s First Name ‰Yes ‰No Video of Student ‰Yes ‰No Student’s Full Name ‰Yes ‰No Student’s Voice (e.g., radio) ‰Yes ‰No Student’s E-mail Address ‰Yes ‰No Student’s Quote (e.g., newspaper) ‰Yes ‰No

I understand that U. S. copyright law protects my child’s work. I also understand that the School District has no responsibility to, nor will it, enforce U.S. copyright law pertaining to my child’s work.

I certify that my child will only submit work that he or she has created. My signature below acknowledges that I grant permission for my child’s work to be published and/or viewed by others and for my child to participate in activities such as those described above. In granting this permission I understand the “Student Privacy Guidelines” stated above will be followed.

Parent / Guardian Signature: ________________________________________ Date: _________

Student Section: I have read the information above and/or discussed it with my parents. My signature below acknowledges that I grant permission for my work to be published and/or viewed by others and that I certify I will only submit work that I have created. I also understand that the School District has no responsibility to, nor will it, enforce U.S. copyright law pertaining to my work.

Student Signature (Required for students in grades 3 – 12): _________________________________ Date: _________

6/7/2003