Parental Permission to View PG or PG-13 Video/DVD

Policy Code: 
Adoption Date: 
Tuesday, January 27th, 2009

Parental Permission to View PG or PG-13 Video/DVD

Teacher _________________________Subject ________________ Grade Level  ________       


The following video/DVD will be used in class on (date) ___________________             

 ________video/DVD shown in its entirety                   _____appropriate clip previewed

                                                                                                     by the teacher named on this form


Title  _______________________________________________________

Rating ___________________



Causes of Rating:




Relationship between video/DVD content and the curriculum:






Alternative activity for those not viewing the video/DVD


______I give permission for (student) ______________________________________________ to view the video.



Parent/Guardian Signature ______________________________________________________ Date _____________


______Rather than viewing the video, I would like my son/daughter to participate in the alternative activity.



Parent/Guardian Signature ______________________________________________________ Date ______________



Non-Discrimination Statement

Iron County School District is committed to a policy of equal employment opportunity and does not discriminate in the terms, conditions, or privileges of employment on account of race, age, color, sex, national origin, physical or mental disability, or religion or otherwise as may be prohibited by federal and state law.

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