Grand Blanc Community School District Technology and Media Access - Opt Out Form I.

Network Access ________ I DO NOT give permission for my child to access the District Network. This will disable computer log-ins, website access, and Google App access.

II.

Posting of Student Work or Images I DO NOT give permission for the below named student’s work, photograph, video image, and/or recorded statement(s) to be posted on District web sites, social media pages and/or other electronic media in order to highlight student achievement, portray examples of educational experiences, etc.

III.

Media Opt Out ________ I DO NOT give permission for my child to be photographed or filmed by the media outlets or other organizations for use in print, television, film, or Internet publications.

For a Student Under the Age of 18  Parent/Guardian Name (printed)___________________________________________  Date__________________  Parent/Guardian Signature_______________________________________________________________________              (Not necessary for students age 18 or older)  Student’s Name_______________________________________________________________  Home Address________________________________________________________________  Student ID Number________________________   Daytime Phone______________________ 

For a Student Age 18 or Older  Student Name (printed)___________________________________________  Date__________________  Student Signature_______________________________________________________________________    

PLEASE RETURN THIS FORM TO THE BUILDING SECRETARY

FORM 4114

Created April 1, 2014, Revised April 13, 2015