ECDC Classroom Work Sample/Photo Release Form
I request permission to collect/use the (attached) work samples and/or videos to complete course assignment requirements for
(Course name)
I understand that these items may not be (Course name) used for any other purpose and that no information may be included in the completed assignment that constitutes a breach of confidentiality.
Name
First
Last
Signature
Date
Month
Day
Year
I give permission for the attached work samples/videos to be used as described.
Name
First
Last
Signature
Date
Month
Day
Year
Consent
Check this box if you want the work samples/videos/artifacts returned to you after the assignment/project has been completed and returned to the student by his/her professor.