Department of Middle, Secondary and K-12 Education

9201 University City Blvd, Charlotte, NC 28223-0001 t/ 704.687.8875 f/ 704.687.6430 www.uncc.edu

Media Consent Form

I, hereby, consent to being photographed, videotaped, or audiotaped by the University of North Carolina at Charlotte and its affiliates in connection with the Experiencing The Other Field Assignment for the doctoral seminar EDCI 8182 Power, Privilege, and Education; provided, however, that UNC Charlotte and its affiliates have authority to use or reproduce such photographs/digital images, video recordings, or audio recordings for UNC Charlotte educational purposes only. I understand that UNC Charlotte and its affiliates will transfer such photographs/digital images, video recordings, or audio recordings to a video podcast to be streamed via a private YouTube link made assessable to a highly restrictive audience of UNC Charlotte professors and doctoral students. I also understand that UNC Charlotte and its affiliates will not distribute such photographs/ digital images, video recordings, or audio recordings to any third party for any other purpose without my further written consent and agreement. And, I understand that I will not be compensated for my time or the use of such media. I release UNC Charlotte and its affiliates from any and all liability arising out of the use of my video reproductions and sound recordings, including without limitation any claims arising out of my right of privacy or right of publicity and any claims based on any distortions, optical illusions or faculty mechanical reproductions of any such images. For additional information, or questions, regarding media consent for the identified project, listed above, contact Dr. Bettie Ray Butler. She can be reached via email at Bettie.Butler@uncc.edu Dr. Bettie Ray Butler Assistant Professor of Urban Education

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If the participant is under age 18, the parent or guardian must also complete the following: I hereby approve the foregoing authorization.

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Middle Grades Education Secondary Education Teaching English as a Second Language

Foreign Languages Education Arts Education Ph.D. in Curriculum and Instruction

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