PARENT/GUARDIAN VIDEO/FILM RELEASE FORM

Date 1/17/17
Dear Parent/Guardian:
Christi Barrett
Superintendent

Dr. LaFaye Platter

Deputy Superintendent
Dr. David Horton
Assistant Superintendent
Vince Christakos
Assistant Superintendent

Professional
Development Service
Center

I am planning to show the PG-13 rated video/film to my class as part of our unit
and/or lesson on The Roaring 20s/The Great Gatsby Novel.
Description of the video/film An adaptation of F. Scott Fitzgerald's Long Island-set
novel, where Midwesterner Nick Carraway is lured into the lavish world of his
neighbor, Jay Gatsby. Soon enough, however, Carraway will see through the cracks of
Gatsby's nouveau riche existence, where obsession, madness, and tragedy await.
Rated PG-13 for some violent images, sexual content, smoking, partying and brief
language
Your child will not be permitted to view the presentation without your permission.
Please return the bottom of the form by 1/18/17.
If your child will not view the video/film, an alternative structured learning activity
will be provided
Sincerely,

1791 W. Acacia Avenue

Hemet, CA 92545
(951) 765-5100
Fax: (951) 765-5115

Teacher
Professional
Development Academy
2085 W. Acacia Avenue
Hemet, CA 92545
(951) 765-5100
Fax: (951) 765-6421
www.hemetusd.org

****************************************************************
Date ____________ Teacher Mrs. Mora
My child, _____________________________________, has permission to see
_____________________________________________ (film).
I understand that the film will be incorporated as part of the planned, systematic,
direct teaching activities.

Governing Board
Marilyn Forst
Megan Haley
Vic Scavarda
Patrick Searl
James Smith
Ross Valenzuela
Joe Wojcik

Parent/Guardian

Board Policy E(1) 6161.11 October 20, 1998

/var/www/apps/conversion/tmp/scratch_7/342875505.doc