Parental
Permission Form
Posting of Personally Identifiable Information
Parental Permission Form
Parental Permission Form Downloadable formats:
This form is to be used by parents to give consent for their child to participate in the Center for Educational Technologies® /NASA Classroom of the Future™ activities and to receive specific recognition, including a photo and/or personally identifiable information beyond first name city/state/country, in connection with that child's participation, original submission to, or news item covered by, CET/COTF's general Web site.
I am the parent and/or legal guardian of ________________________ (first and last name of child), who will submit personal information to CET/COTF and/or will participate in one of CET/COTF's activities, including, but not limited to online chats. Therefore, I am giving CET/COTF permission to use:
_____ A photograph of my
child
_____ A photograph taken by my child
_____ An original creation written/developed by my child
_____ A news story about my child
_____ An original piece of artwork created by my child
_____ My child's participation in online chats
I would like my child to receive specific recognition, including the posting of certain personally identifiable information for my child's submission/participation in CET/COTF activities and/or a news item about my child on CET/COTF's general web site. Therefore, my signature below, I give permission to CET/COTF to post the materials checked above on its general web site, along with any combination of the following information about my child that may be personally identifiable when posted (check and complete the information that you would like to appear; CET/COTF reserves the discretion to edit the combination of the information provided on this form prior to posting on its web site:
_____ A photograph
of my child
_____ My child's first name: ________________________
_____ My child's last initial: _____ or last name: _________________
_____ My child's age: _____
_____ My child's city/state/country:________________________
_____ My child's school or organization: ______________________
_____ Other information about my child: ______________________
In making my decision to give permission with this form, I have carefully reviewed the CET/COTF Privacy Statement.
_________________________
_________________________
Signature of
parent/guardian Printed name of parent
_________________________
_________________________
Date
Daytime phone number
When you have completed and signed this form, please fax it to CET/COTF at (304) 243-2497 Attn: Intellectual Property. In the alternative, you may mail it to Intellectual Property, Center for Educational Technologies, Wheeling Jesuit University, 316 Washington Avenue, Wheeling, WV 26003. If you wish to opt-out or change anything on this form, you may contact CET/COTF by either method above or phoning (304) 243-2388.
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Last updated on November 10, 2004