This form is for media interviews with students for publications and programs. Parent's permission must be obtained prior to television, film, video or print publication interviews. This also applies to photographs of students taken for the various media.

I, ______________________, the parent of ______________________,

(Parent's name above)                  (Student's name above)

do grant my permission for my son/daughter to appear in an article/photograph/televised news program produced by Rutgers Center for Information Management. Integration, and Connectivity, 180 University Ave, Newark, NJ 07002, in partnership with Newark Public Schools.

I understand that this interview is designed to showcase my son/daughter's participation in an academic setting and is not for a profit venture. Therefore, no fees will be paid to me or my child by said organization, individual, or company.





Parent/guardian signature


Street address, city and state