Excerpt from Video Presentation Permission Form
Mary O'Dell

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.)

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?

Which is a valid conclusion that can be drawn from reading this form?
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.