FLVS Media Release

Student Name: Student Name: First Last
Parent Name: Parent Name: First Last
Email Address:
Current Grade Level:
Student FLVS Username:
Please check the appropriate box below.

Please check the appropriate box below. Full Name Permission: I give permission for my child’s work, photograph, and accomplishments, which will be accompanied by the child’s full name (first and last), to be electronically displayed by Florida Virtual School. I hereby release Florida Virtual School from any liability resulting from or connected with the publication of such work. First Name Only Permission: I give permission for my child’s work, photograph, and accomplishments, which will only be accompanied by the child’s first name, to be electronically displayed by Florida Virtual School. No last name will appear on any materials that are displayed. I hereby release Florida Virtual School from any liability resulting from or connected with the publication of such work.
I am the parent, legal guardian, or authorized representative of the student named above. I represent and warrant that I have the full legal authority to enter into this Agreement. I have read the information regarding the display of student work.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Upload Photo or Video (if applicable)

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Date: Date: / MM / DD YYYY