Teaching, Learning and Educational Studies

Authorization for Use of Personally Identifiable Information for Media and Marketing Purposes

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Purpose of this form

Western Michigan University (WMU) Summer Camp for Future Educators is committed to protecting the privacy of students’ personally identifiable information (PII)[1]. The Family Educational Rights and Privacy Act (FERPA) gives you protections regarding the use and release of students’ personal information. This federal law[2] requires that we obtain your/your student’s authorization to disclose this information for the purpose identified below.

Authorization

I authorize the WMU Summer Camp for Future Educators to use and discuss my child’s first name and image for marketing and promotional purposes.
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 this WMU’s Summer Camp for Future Educators interview, testimonial, photos or video.
I understand that WMU cannot control photography and/or filming between students.

Exceptions

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 the WMU Summer Camp for Future Educators is no longer using the interview, testimonial, photograph, or video, whichever comes first. I understand that I may revoke this authorization at any time by submitting a written request to WMU’s Summer Camp for Future Educators. 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.

Waivers

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.

[1] 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.

[2] See 20 U.S.C. § 1232f, et seq.; 34 C.F.R. § 99.1, et seq.

Date (required)

Name of Minor for Whom this Disclosure Applies (required)

Name of Individual Authorizing Disclosure (required)

Relationship to Minor (required)

Electronic Authorization (required)

I have read and understand the terms of this authorization, and I have had an opportunity to ask questions about WMU’s use of my child’s PII for possible use in broadcast or publication. I hereby knowingly and voluntarily consent to WMU using my child’s PII for the purposes stated herein. I represent that I am 18 years of age or older and am legally competent to authorize this release. I may request a signed copy of this authorization.

* I have read and understand the above authorization for use of personally identifiable information for media and marketing purposes.