(Attachment C)

DOE WWW PARENTAL CONSENT FORM

I hereby give permission for my child's photograph, artwork, poetry or other work produced in conjunction with a school project, class or extracurricular activity, to be put on Mr. Leopold's Music Classroom on the Internet at http://www.erols.com/leopold, in accordance with the policies set forth in the DOE's Internet Acceptable Use Policy.

I understand that the information to be posted does not include information from my child's academic, guidance,
permanent or cumulative record (i.e. grades or attendance records). I also understand that the information to be
posted does not include other personal identifiable information such as my child's address, phone number, or social
security number.

Name of student:

_____________________________________________

Parent's signature:

_____________________________________________

Date:

______________________________________________

This document is to be sent to and retained by the school.