Photo & Video Release

Child's Name*
First Last
Miriam Academy students may be photographed and recorded throughout their school year for a variety of reasons. Please indicate your permission preference regarding your child’s inclusion in photographs or videos.
Permission Preference*
My child can have his/her picture taken while attending Miriam Academy if the images are distributed or viewed inside the Miriam Academy community, such as in the yearbook, mailings and emails sent only to the Miriam Academy community, the end of year video, and in class projects.
- I agree
- I do not agree
Permission Preferences*
My child can be photographed or recorded while attending Miriam Academy if the images are distributed or viewed outside the Miriam Academy community, such as in newspapers or magazines, on television footage, on the Miriam Academy website and social media outlets, in brochures and for public relation purposes. My permission noted below also allows my child to be identified by first and last name ONLY when required by the media.
- I agree
- I do not agree
Parent / Guardian Signature*
First Last
Date*
Date Format: MM slash DD slash YYYY
Pin Number*
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