Parent's Name *

First Name

Last Name

Student's Name *

First Name

Last Name

Student's Date of Birth *

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DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

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Phone *

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Image Consent *

Dear Parents, I have received several requests to share the many projects and work we do in After-School STEM with Mr Bob via electronic media. This year I would like to make that happen and share our work via Mr-Bob.org. As a first step, I would need your permission to use photos and or videos of your child at Mr-Bob.org. I take your child’s privacy seriously and would never release or publish last names, home address, phone number, etc. The photos and videos would be of the classroom activities and their results. If you have any questions or exceptions please let me know, I would be happy to work with you. Please check one of the boxes below. Thank you for enrolling in After-School STEM with Mr Bob.

YES! I give permission for my child to be photographed and posted to Mr-Bob.org under the conditions stated above.

NO! I do not give permission for my child to be photographed and posted to Mr-Bob.org.