Permission Slip for Student Involvement:
Social Media and Website Communications
At times during and after the school day, Dickens Library Media Center (LMC) staff may ask to interview, photograph,
audiotape, film, and/or videotape your child to document a variety of authentic learning experiences. This material may
be utilized in media that includes, but is not limited to, the school library media center website, internal or external
publications and communications including social media websites, and so on.
Your signature on the form below authorizes the Dickens Elementary School LMC staff to release your child’s FIRST
name only, photograph, and/or audio/video/film production for publication related to LMC functions and activities.
Examples may include, but are not limited to, student podcasts, video or audio book talks, digital photo stories,
individual or group achievements, photo archives, presentations, and so on.
In addition, your child will be completing a variety of projects and assignments within the Library Media Center this year
that involve the use of computers and the Internet for research. Our LMC website is extensive and is used for
instruction. It also contains many resources for you and your child to use both at home and at school.
Student safety on the Internet is my first concern. Prior to beginning work on the Internet, all students will complete an
in-depth training with the Dickens LMC staff. Additionally, all sites accessed by students within the LMC will be used
under close supervision.
Once signed and dated, this form shall remain in effect until the end of the current school year. At any time during the
school year, however, you may revoke this permission for future use by notifying, in writing, the principal of Dickens
Elementary School, Dr. Barbara Reininger.
Mrs. Christina Bentheim, M.Ed.
School Library Media Specialist
_____ Yes, I give the Dickens LMC permission to use my child’s information as described above.
_____ No, I do not give Dickens LMC permission to use my child’s information as described above.
Student Name ___________________________________ Teacher Name ____________________________
Parent Signature _________________________________ Date ____________________