LAUSD Media Release Form (English)

Los Angeles Unified School District Parent/Guardian Publicity Authorization and Release
Dear Parent/Guardian:
The Los Angeles Unified School District requests your permission to reproduce through printed, audio, visual, or electronic meansactivities in which your pupil has participated in his/her education program. Your authorization will enable us to use speciallyprepared materials to (1) train teachers and/or (2) increase public awareness and promote continuation and improvement ofeducation programs through the use of mass media, displays, brochures, websites, etc.
1. Name of Pupil (please print)
2. Birthdate (please print)
3. Name of Parent (please print)
a. I, as a parent of guardian, of the above named pupil fully authorize and grant the Los Angeles Unified School District and its authorized representatives, the right to print, photograph, record, and edit as desired, the biographical information, name, image, likeness, and/or voice of the above named pupil on audio, video, film, slide, or any other electronic and printed formats, currently developed, (known as “Recordings”), for the purposes stated or related to the above.
b. I understand and agree that use of such Recordings will be without any compensation to the pupil or the pupil’s parent or guardian.
c. I understand and agree that the Los Angeles Unified School District and/or its authorized representatives shall have the exclusive right, title, and interest, including copyright, in the Recordings.
d. I understand and agree that the Los Angeles Unified School District and/or its authorized representatives shall have the unlimited right to use the Recordings for any purposes stated or related to the above.
e. I hereby release and hold harmless the Los Angeles Unified School District and its authorized representatives from any and all actions, claims, damages, costs, or expenses, including attorney’s fees, brought by the pupil and/or parent or guardian which relate to or arise out of any use of these Recordings as specified above.
My signature shows that I have read and understand the release and I agree to accept its provisions.
4. Signature of Parent/Guardian
Clear
4. Signature of Parent/Guardian
Clear
5. Date Signed
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
6. Address (Number, Street, Apartment Number)
7. City
8. State
9. Zip Code
10. Telephone
11. Principal
12. School
Approved as to form by the Office of the General Counsel.
This form shall not be amended without written approval of both the Office of the General Counsel and the Office of Communications/Public Information
Should be Empty:

Los Angeles Unified School District Parent/Guardian Publicity Authorization and Release

Dear Parent/Guardian: