Urbana High School 500 Washington Avenue Urbana, Ohio 43078 www.urbana.k12.oh.us/uhs Phone 937-653-1412 Fax 937-653-1487

Kristin Mays, Principal

Thomas Marchetti, Asst. Principal

Video Equipment Permission and Acceptable Use Form Introduction Students in Video Productions I, II, or III utilize school video equipment during the school day for practice and completion of class projects. At times, it would be advantageous for the student to sign out video equipment for outside of class/school use to complete assignments/projects. Each of the video cameras and accessories available for sign-out are valued at approximately $700.00. For this reason, we require a student and parent signature before the equipment can be assigned to a student.

Parent Responsibility and Permission I am authorizing the assignment of the designated video equipment to my child. I understand that it is to be used as a tool for completion of assigned projects and that my child will comply with the Urbana City Schools Acceptable Use Policy and will not utilize the equipment for personal use or download any video to the Internet without written permission from the Video Productions teacher and school administration. I will help ensure the safe and timely return of the equipment the next school day. I also understand that I am financially responsible for any willful, malicious, or accidental damage to the equipment as well as any charges resulting from content videotaped and/or downloaded from the equipment without written permission from the Video Productions teacher and school administration. I understand that my child may lose future use privileges if the equipment is either damaged or not returned within the designated time. GUARDIAN NAME (printed) ______________________________________________________ GUARDIAN SIGNATURE _______________________________________ DATE ___________ GUARDIAN CONTACT INFO (phone and E-mail) _____________________________________

Student Responsibility and Permission I agree to take care of the video equipment and accessories while it is in my possession. I will not throw, drop, or damage the equipment in any way. I will carry the equipment in the authorized case. I will not give the equipment to any other person (including other students) for his/her use. I will use the equipment in the appropriate manner. I will NOT download any video to the Internet without written permission from the Video Productions teacher and school administration. I agree to return the equipment in good condition the next school day. STUDENT NAME (printed) _______________________________________________________ STUDENT SIGNATURE ________________________________________ DATE __________ This form is adapted from an original creation by school librarian Kathy Parker at http://marianslibrary.wordpress.com/