AUTHORIZATION FOR USE OF PERSONALLY IDENTIFIABLE INFORMATION FOR MEDIA AND MARKETING PURPOSES (MINOR)
Purpose of this Form
Western Michigan University’s (WMU) Academically Talented Youth Program (ATYP) is committed to protecting the privacy of students’ personally identifiable information (PII). The Family Educational Rights and Privacy Act (FERPA) gives you protections regarding the use and release of students’ personal information. This federal law requires that we obtain your/your student’s authorization to disclose this information for the purpose identified below.
- I authorize ATYP to use and discuss my child’s first name and image for marketing and promotional purposes. Specifically, brochures, website, and advertising.
- A copy, fax, or electronic version of this authorization will be as valid as the original.
- I understand that I/my student will receive no monetary compensation for my appearance in these marketing materials
- I understand that WMU cannot control photography and/or filming between students.
- This release does not apply to health records that are protected by the Health Information Portability and Accountability Act (HIPAA).
Effective Dates and Revocation
This authorization is effective for five years, or until ATYP is no longer using the likeness, whichever comes first. I understand that I may revoke this authorization at any time by submitting a written request to ATYP. The revocation will not apply to information that has already been disclosed. I understand that, once disclosed, my information may be re-disclosed by a non-WMU entity.
I also release and hold harmless WMU, its representatives, and its delegees from and against any claim for any injury related to use of my child’s image, voice, likeness, name or any other identifying characteristics obtained from the activities identified in this authorization. I further release and hold harmless WMU, its representatives, and its delegees from any and all liability due to alteration of or use of my child’s information in composite form that may occur in the making or processing of said medium.
Although I have the right to a copy of any of my child’s information that is released, I waive any right to inspect and/or approve the finished product that may be used in connection with this authorization.
 Personally Identifiable Information includes: 1) name; 2) name of student’s parent or other family representatives; 3) address of student or family; 4) a personal identifier (e.g., social security number, student number, biometric record); 5) other indirect identifiers (e.g., date of birth, place of birth, mother’s maiden name); 6) “other information that, alone or in combination, is linked or linkable to a specific student that would allow a reasonable person in the school community, who does not have personal knowledge of the relevant circumstances, to identify the student with reasonable certainty”; or 7) “Information requested by a person who the educational agency or institution reasonably believes knows the identity of the student to whom the education record relates.” 34 C.F.R. § 99.3.