(Please use one form for each child)
Print, Complete, Sign & Mail to: James Monroe Foundation, 1009 Bainbridge Street, Richmond, VA 23224
I HEREBY UNCONDITIONALLY GRANT MY PERMISSION AND CONSENT TO YOU TO COLLECT ANY OF MY CHILD’S PERSONALLY IDENTIFIABLE INFORMATION AND CLASS WORK WHICH HE OR SHE MAY PROVIDE TO YOU FOR THE PURPOSE OF REVIEW, EDITING AND POSSIBLE PUBLICATION AT JAMESMONROE.ORG AND ITS AFFILIATED INTERNET SITES. I HEREBY STATE AND AFFIRM THAT I AM THE LEGAL GUARDIAN OR PARENT OF THIS CHILD AND THAT I AM OVER THE AGE OF 18 YEARS OLD.
I HEREBY UNCONDITIONALLY GRANT MY PERMISSION AND CONSENT TO THE JAMES MONROE FOUNDATION FOR UNLIMITED PUBLICATION (IN TOTAL OR EDITED) AND BROADCAST, USE, FOR THE INCORPORATION INTO JAMES MONROE FOUNDATION WEBSITES, OR OTHER MEDIUMS, OF ANY SUBMISSIONS AND THAT THEY MAY BE USED IN ANY CURRENT OR FUTURE ADVANCES IN THE STATE OF COMMUNICATION THAT MAY BE DEVELOPED FOR JAMES MONROE FOUNDATION PUBLICATION AND/OR BROADCASTING.
I UNDERSTAND THAT I MAY REVOKE THIS CONSENT BY GOING TO JAMESMONROE.ORG AND PRINTING THE REVOCATION FORM, COMPLETING IT, SIGNING IT, AND MAILING IT BACK TO: JAMES MONROE FOUNDATION, 1009 BAINBRIDGE STREET, RICHMOND VA 23224.
I UNDERSTAND THAT I MAY CHOOSE TO HAVE MY CHILD’S FIRST AND LAST NAME OMITTED FROM PUBLICATION ON ANY JAMES MONROE FOUNDATION WEBSITE BY PROMINENTLY STATING THIS ON MY CHILD’S SUBMISSION NEXT TO THEIR NAME. I UNDERSTAND THAT IF AN ACTUAL NAME IS NOT USED, A SCREEN NAME INCLUDING CITY, STATE, CLASS NAME, CLASS CATEGORY (PRIMARY, SECONDARY, COLLEGE, OR SOME LEVEL IN SCHOOL) AND SCHOOL IDENTIFIER MUST BE PROVIDED.
I UNDERSTAND THAT IT IS THE JAMES MONROE FOUNDATION’S POLICY NOT TO PUBLISH OR BROADCAST ANY MINOR STUDENT’S LAST NAME ON ANY JAMES MONROE FOUNDATION WEBSITES IF THIS CHECKBOX IS MARKED IN ANY WAY.
I UNDERSTAND THAT THE PRIVACY POLICY MAY CHANGE FROM TIME TO TIME. THE MOST CURRENT FORM CAN BE FOUND AT HTTP://WWW.JAMESMONROE.ORG/CONSENT.HTML OR BY REQUESTING A COPY THROUGH THE MAIL FROM THE ADDRESS LISTED AT THE BEGINNING OF THIS DOCUMENT. I UNDERSTAND THAT MY CHILD CAN NOT REGISTER WITH THE SITE AND PARTICIPATE IN THE ACTIVITIES OF THE SITE WHERE PERSONALLY IDENTIFYING INFORMATION IS COLLECTED UNLESS AND UNTIL I SIGN, DATE, COMPLETE, AND RETURN THIS FORM TO YOU.
I UNDERSTAND THAT BY SIGNING MY NAME BELOW I AM GIVING PERMISSION FOR PERSONALLY IDENTIFIABLE INFORMATION ABOUT MY CHILD TO BE COLLECTED AND PUBLISHED. I UNDERSTAND THAT THE FORM I AM SIGNING WAS OBTAINED FROM JAMESMONROE.ORG. THIS FORM MAY HAVE BEEN PROVIDED TO ME BY MY CHILD, BUT I AM ASSURING YOU THAT I AM THE LEGAL GUARDIAN OR PARENT OF THIS CHILD AND RESIDE IN THE IMMEDIATE HOUSEHOLD OF THIS CHILD.
THE FOLLOWING REQUIRED INFORMATION WILL BE USED FOR VERIFICATION PURPOSES.
Child’s first name: _______________ Child’s last name: _______________
Child’s screen name (If this option is selected) (No last names): _________________
Child’s Email address: ____________________________
Parents Email : _________________________________
Parent/Legal Guardian name: ____________________________________
Address: ____________________________________________________________________
____________________________________________________________________
School name: ___________________
School phone number: ______-- ________-- _______
School Address: ______________________________________
______________________________________
Parent/Legal Guardian Signature: ____________________________
Date: ____________
