HOUSTON INDEPENDENT SCHOOL DISTRICT WEST UNIVERSITY ELEMENTARY SCHOOL Texas Education Agency Exemplary School Texas Business & Education Coalition Honor Roll School Texas Monthly Best Public School in Texas 3756 UNIVERSITY BLVD. HOUSTON, TX 77005-2898 TEL (713) 295-5215 - FAX (713) 667-8514 John T. Threet, Principal HOUSTON INDEPENDENT SCHOOL DISTRICT STUDENT MEDIA RELEASE FORM West University Elementary School is frequently asked to participate in media events. Many times we are given short notice of media visits to the school. As a result, we are requesting permission in advance for your child to appear in any screened media events that may occur this school year including, but not limited to, television, radio, and newspapers. All media events are approved by the HISD Press Office and our school principal. You may withdraw your permission for your child to participate in media coverage at any time by notifying us in writing. ____I grant permission to the Houston Independent School District and West University Elementary School to use the media (television, radio, and/or newspaper) on which appears. my child (print child’s name) ____I do not grant permission for my child to (print child’s name) participate in any media event. ___________________________________________ Printed name of parent/guardian ___________________________________________ Signature of parent/guardian ___________________________________________ Address ___________________________________________ Date PLEASE COMPLETE AND RETURN TO YOUR CHILD’S TEACHER Creating a College-Bound Culture It is the policy of the Houston Independent School District not to discriminate on the basis of age, color, handicap or disability, ancestry, national origin, marital status, race, religion, sex, veteran status, or political affiliation in its educational or employment programs and activities.