ANDERSON SCHOOL			

		INTERNET PUBLICATION PERMISSION			
			
		I understand that my child’s photograph or work (writing, drawings, etc.) may occasionally be published on the Internet and be accessible on a World Wide Web server.  I give my permission to publish my child’s photograph or work with identification as specified below.			
		
Please circle “Yes” or “No” for each of the following:	

		1.  My child’s work (writing, drawings, etc.) may be published on the Internet. 

Yes        No			
			
		2.  My child’s photograph (individual or as part of a group) to be published on the Internet.                                

Yes        No

3.  My child’s first name may be used to identify his/her work or photograph.

Yes        No			
			
		4.  My child’s class (teacher/grade level/school) may be used to identify his/her work.                  

Yes        No			

Please list any other restrictions you wish to place on the identification of your child’s published work. 

__________________________________________________________________________________			
			
		Parent or Guardian name (print)________________________________________________________			
			
		Parent or Guardian signature _______________________________________  Date ______________			
			
		Student name (print) _________________________________________________________________			
			
		Student signature _________________________________________________ Date ______________			
			
		Sponsoring Teacher Name (print) ______________________________________________________			
			
		Signature ______________________________________________________  Date ______________			

		THIS DOCUMENT SHALL REMAIN VALID UNTIL REVOKED IN WRITING BY PARENT/GUARDIAN.