Department of Education
Honolulu, Hawaii
Student Publication/Video
Release Form
This form combines and replaces the previous Student Permission to Videotape/Record and Reproduce Work Forms. By signing these forms, you agree to the terms and conditions of this agreement. Please complete the following:
1. Print all of the following legibly. Use blue or black ink.
2. Check the boxes below.
3. Sign this form.
4. Distribute as instructed.
I hereby give my permission to the Hawaii State Department of Education to use my work, videotape, or otherwise record my name, voice, and/or likeness in its publications. I understand that examples of my work and/or these recordings of me will be used exclusively for non-commercial, educational purposes, which may include, but not limited to, distribution by print, internet, or digital media and open-circuit broadcast, closed-circuit, and/or cable television transmission within or outside of the State of Hawaii for the duration of the media.
I understand that there will be no financial or other remuneration for use of my work and/or recordings, either for initial or subsequent transmission or playback, and I hereby release the Hawaii State Department of Education from any liability resulting from or connected with the publication of such work. Permission is granted for the duration of the media. I further understand that my permission or consent may be rescinded; however, in order for the revocation of permission/consent to be effective, it must be made in writing and said revocation will not affect the publication or work that has already been produced.
The Department of Education may use my name, likeness, work, and/or bibliographical identification for publicizing and promoting the use of these recordings.
The HIDOE has permission to videotape or otherwise record my name, voice, and/or likeness for educational purposes.
yes no
The HIDOE has permission to use my work for educational purposes.
yes no
Name (Please Print)
School
Home Address
City, State, Zip Code
Title
Signature
Date