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Media Waiver


This form must be completed in order to participate in Summer at Siena.
Media Release Form
Summer at Siena 2017
Dear Parent/Guardians:
At different times throughout the year, Siena may take the opportunity to display or publish creative work produced by students or photographs of students. Such photographs and/or work may be displayed in our building, submitted to local newspapers and other media outlets, and/or published on our web page or in our newspaper, newsletter or brochures. Please complete and return this permission form to Siena by opening day to let us know how you wish your child’s work or photographs to be displayed or published.
I give permission for my child’s creative work and photograph to be used for internal display or publication (building displays, yearbook, parent/student newsletter, etc.)
Yes
No
I give permission for my child’s creative work and photograph to be used for external display or publication (web site, submission to newspapers, Siena brochures, etc.)
Yes
No
Student Name
Parent/Guardian Name
Parent/Guardian Electronic Signature
Yes
Date
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Parent/Guardian Email
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