Written Release Form

Name of Interviewee or Guest Presenter (print): __________________________________

Address: _________________________________________________________________

Phone: ( ____ ) ____________________ Email: _________________________________

Place of Presentation: ______________________________________________________

Name of Interviewer or Site Organizer (print): ___________________________________

School: ________________________________________ Date: ____________________

I understand that this interview and any photographs, tape recording, or video recording are part of scholarly research by students at the the school named above. I give permission for the following (check all that apply).

______May be used for educational purposes and research

______May be used for up to 30 days
______May be used for up to 90 days
______May be used for the current school year
______May be used for 2 years
______May be used indefinitely
______Other: _______________________________________

______Medium used for educational purposes and research

______May be used as part of a distance education presentation
______May be used for video tape and or DVD reproduction and distribution
______May be used for video streaming
______May be used as part of a written publication
______May be used as part of a written online publication

______May include my name

______May be included in another education, nonprofit publication or exhibit

______May be used but DO NOT include my name