Student Exchange Media Consent Form
Please provide the student and guardian details, then review the media permissions for the exchange program. Use the same title exactly throughout the form.
Student Details
Student full name
*
First Name
Middle Name
Last Name
Date of birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
School or program name
*
Exchange destination country or host school
*
Grade or year level
*
Please Select
Kindergarten
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
Postgraduate
Other
Media Consent and Permissions
Consent Decision
*
I consent
I do not consent
Permitted Media Uses
Photos
Video
Audio recordings
Exchange-related communications
Website
Social media
Printed materials
Internal documentation
Restrictions or Notes on Permitted Use
Guardian and Contact Information
Guardian or Student Full Name
*
First Name
Middle Name
Last Name
Relationship to Student
*
Please Select
Mother
Father
Legal Guardian
Grandparent
Other
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: