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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
(Required)
(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
(Required)
First
Last
Signature
(Required)
Your Name
Your Name
Your Name
Your Name
Date
(Required)
Month
Day
Year
I give permission for the attached work samples/videos to be used as described.
Name
(Required)
First
Last
Signature
(Required)
Your Name
Your Name
Your Name
Your Name
Date
(Required)
Month
Day
Year
Consent
(Required)
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.