September 2003

PERMISSION FOR USE OF

PHOTOGRAPHS AND VIDEO

Dear MIT Students,

At various times throughout the MIT Program, photographs or videos may be taken of you during class participation at Evergreen or while you are participating in an internship or field experience in the community.  With your permission, the photographs and/or videos may be chosen for college recruitment and publications, including the Master In Teaching catalog, brochure, web pages, newsletter and display boards.  If chosen, the photographs and/or videos will be used exclusively by The Evergreen State College’s Graduate Studies Office and solely for non-profit purposes related to our education program. 

Please check one of the following options and provide your signature.  If you have any questions, please call the Graduate Student Services Office at 360-867-6707.

Thank you.

PRINT YOU NAME: _________________________________________________

CHECK ONE:

__________         I give permission for photographs and/or videos to be taken of me and used by TESC for college publications.

__________         I do NOT give permission for photographs and/or videos to be taken of me by TESC for college publications.

SIGNATURE:        __________________________________________________

DATE:                   ___________________