MONTGOMERY COUNTY PUBLIC SCHOOLS

Revised 8/23/2013

MCPS Television
850 Hungerford Drive, Room 27
Rockville, MD 20850
301-279-3141
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CONSENT AND RELEASE

Name:

Taping Date: 12/15/21 Taping Location: MCPS Zoom and CESC

Purpose of Taping: BOE meeting with students

Producer/Contact Person: Shella Cherry Phone: 240-740-4692

I hereby consent to the nonprofit use of my likeness and/or voice by the Montgomery
County Public Schools and its assigns, for all purposes of education, instruction, or public
information, on the MCPS cable TV channel, the MCPS web site, and the MCPS YouTube
site. The use of this content is for educational purposes only.

I am of legal age* and competent to execute this consent and release, which I have read
and fully understand.

Print Name Date

*Signature Of Parent Or Guardian

If Individual Is Under Age 18

www.mcpstv.org