(Note: This form may be printed out and turned in to the front office of the school. Parent signature required.)

School: South Lake Middle School                    Address: http://www.southlakems.org

Student Name:_______________________________________________________________

Grade:________________________________________ Wing_______________

Humanities Teacher:________________________________________

Relative to my child, I hereby give permission to South Lake Middle School to:

§ Incorporate a recognizable digitized image, still or video, on a school Internet web page. This image will only have your child’s name attached if you give separate permission at the time of publication.

YES        NO

§ Incorporate my child’s voice with connection to their image. This would be used to publish vocal concerts. No name would be attached without a separate permission form.

YES        NO

§ Use my child’s first and last name in connection to their image. This would only be done if they are being recognized for a special award.

YES        NO

Parent Name:________________________________________________ Date:_________________
(please print)

Parent Signature:_____________________________________________

Note: If your child's picture, voice, or name accidentally appear on the website, please contact the webmaster immediately and it will be removed. Thank you.  web-sl@iusd.org

South Lake Middle School / 655 West Yale Loop
Irvine, CA 92614 / Phone: (949) 936-6700 / Fax: (949) 936-6709