2009-2010 Parent/Guardian Media Consent Form

New Jersey FBLA is creating programs to highlight chapter activities. A new program (Media Spotlight) will allow chapters to submit video and photos of its

chapter activities (fundraisers, community service, events, etc.).

This form is to request permission for your child's name and photo or video to be published on the New Jersey FBLA web site, www.njfbla.org. Pursuant to law, we will not release your child's name and photo or video without prior written consent from you.

In recognizing FBLA member and chapter achievement, your child's name, photo, or video associated with his/her school, may be published on the web site.

If you wish to rescind this agreement you may do so at any time by sending a letter to the NJ State FBLA Chairman, Ellen Benowitz, MCCC, PO Box B, Trenton, New Jersey 08690.

Please complete the following information and mail or fax this form to the NJ State FBLA Office at 609-570-3887.

_____ I GRANT permission for my child's name, photo or video to be published on the NJ FBLA web site.

________________________________________________________________________________(Student's Name)

________________________________________________________________________________(Name of School)

________________________________________________________________________________(Name of Parent/Guardian and Relation to Student)

________________________________________________________________________________ Signature of Parent/Guardian Date

FUTURE BUSINESS LEADERS OF AMERICAPH

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NEW JERSEY STATE CHAPTERMERCER COUNTY COMMUNITY COLLEGE

1200 Old Trenton RoadPO Box B

Trenton NJ 08690(609) 570-3766