School Web Page Use of
Student Image Permission Form
By completing the following form you give permission to have your image (picture) used on the Adam Scott web page (http://www2.kpr.edu.on.ca/acvi or http://adamscott.ca).
You may request to have your image removed at any time.
Student Name (Please Print)
Student Signature (Please Sign)
Date
Parent/
Guardian’s Signature
(If student is under 18 years old)
OFFICE USE ONLY
DATE:
STUDENT NUMBER