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Release Form

NEW YORK STATE EDUCATION DEPARTMENT
THE UNIVERSITY OF THE STATE OF NEW YORK
OFFICE OF VOCATIONAL AND EDUCATIONAL SERVICES FOR INDIVIDUALS WITH DISABILITIES (VESID)

Permission to Use Photograph, Audio, or Written Description or Account in a Publication

Date _______________

Name __________________________________________________________

Current Telephone Number: ______________________________________

I, _____________________________, HEREBY GIVE CONSENT
(Print Full Name)

to The University of the State of New York, the State Education Department, or to an agent or person selected by the Education Department, to use my name: my likeness, such as a portrait, picture, photograph, movie or videotape of me; a recording of my voice, in any form; or a narrative or other written account in publicizing or reporting on its programs, and for any other purpose of the Department. I agree that such likeness, recording or account shall be the property of The University of the State of New York, the State Education Department, and may be so used by the Department.

My consent and agreement herein is given with the knowledge and understanding that The University of the State of New York, the State Education Department, may or will incur expense in connection with such likeness, recording, or account.

Signed ___________________________ Witness _____________________
(TO BE SIGNED BY PARENT OR BY GUARDIAN, IF APPROPRIATE.)

I HEREBY individually and as (Father), (Mother), (Guardian) of the above consent to the foregoing.

NOTE: This consent will expire two years from the date at the top of this form, unless otherwise indicated. Old stock of publications may continue to be distributed.