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Photo Release Form
I understand that the Green Street Teaching and Learning Center and Project to Increase
Mastery of Mathematics and Science may take photos and/or videos of program participants
during program activities and events for use in educational or promotional materials in print,
multimedia, or web form. Photos/videos will only be used for purposes related to these
Wesleyan University programs and their related partners.
Please check the correct box below as to whether you do wish or do not wish to grant Green
Street permission to use your (or your child’s) photos/videos taken during a program.
Additionally, please complete the information below and sign this form in verification of your
permission regarding Green Street’s use your (or your child’s) photos/videos.

☐ I DO grant permission for the use of my (or my child’s) photo/video.
☐ I DO NOT grant permission for the use of my (or my child’s) photo/video.

Name (or child’s name) ____________________________________________