Student Release for Video Taping and/or Photography Form

If requested below, as far as is possible, my anonymity will be maintained. I also
understand that, upon written request, I will be shown any videos or photographs and have the
opportunity to refuse their distribution unless my image is blurred, pixelated or otherwise
obscured.

All fields marked with asterisk (*) are required.

required text field
required checkbox field
You may reveal my name or use it in presentations/publications.*
If you do not want your name used then select "No"
required checkbox field
You do not need to cover my face in images to maintain anonymity.*
If you want your face to be covered to maintain anonymity then select "No"
required date field