Video Broadcast Permission Form
Willow High School
Teacher’s Name: __________________________ Date: __________
Name of Video:____________________________________________
Video rating - G PG PG-13 R NR (not rated) Unknown
(You must have signed parental permission slips for ratings above PG-13)
What alternate activity will be provided for any students who do not have parental permission?
How was the video acquired?
_____ taped from TV/Cable date(_______________)
_____ rented (I have permission to show it.)
_____ owned by the school
_____ teacher owned
_____ other (explain) ____________________________________
Length of video ____________ Date(s) to be shown ________ Blocks(s) you will be showing this video - 1st 2nd 3rd 4th (Circle all that apply)
What essential question(s) are you studying and how will this video relate to them?
What follow-up activities are planned for the video? (1 is required)
Teacher’s Signature _______________________________________
The teacher signed above accepts responsibility for copyright compliance for broadcasting this video.
_____________________________________________
Principal’s signature (or designee)
_____________________________________________
Date
Approval is required for materials not owned by the school
Approved __________ Denied __________
Read the passage on the left to answer the following questions:
26)
What is the purpose of this form?
A) to request a specific video from the Broadcast Center
B) to receive permission from the parents to broadcast a video in a classroom
C) to receive permission from the Video Broadcast Company to use their videos
D) to receive permission from the principal to broadcast a video in a classroom
27)
What is the main idea of the content within this form?
A) Willow High School encourages video presentations in the classroom.
B) Willow High School does not encourage video presentations in the classroom.
C) Parents, teachers, and principals must plan together for essential video presentations.
D) Video presentations require teacher planning and permission from parents and the principal.
28)
"What alternate activity will be provided for any students who do not have parental permission?"
What does the word alternate mean in this sentence?
A) taking turns
B) changing sides
C) hands on, active
D) other, substitute
