State of Hawaii Department of Education Office of Curriculum, Instruction & Student Support Honolulu,Hawaii

This form combines and replaces the previous student permissionto videotape/record and reproduce work forms. By signing these forms,you agree to the terms and conditions of this agreement.Pleas 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 here by give 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 bropadcast, 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 Eduation 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 I further understand that my permission or constent may be rescinded;however, in order for the revoation of permission/consent to be effective, it must be made in writting and said revocation will not affect publication or work that has already been produced.

The department of eduation may use my name, likeness, work,and/or bibliographical identification for publicizing and promoting the use of these recordings.

The HIDOE has permission to use my 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

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Name(please print)

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Title

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School

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Signature

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City,State,Zip Code

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Date