HIGH SCHOOL PERMISSION FORM

(FILM/VIDEO)

Dear Parent:

On                                       the film                                              which

                (DATE)                                    (TITLE OF FILM)

is rated R will be shown in my classroom.

The film will take approximately                             periods.

The film will be used to supplement instruction and falls within the scope and sequence of planned activities for this class. My major reason for using this film is to:

If you wish additional information about the film and how it fits into the curriculum, Please contact me at .

Your student will not be present for the showing of this film without your consent. Please respond to one of the statements below and return the form to me on or before                    . Students excused from the film viewing will be given an alternative assignment during that time.

Sincerely,

Teacher (School and Class)

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My child may view the film.

My child is to be excused from the viewing and is to receive an alternative

assignment.

Student Name                                                        Course                             Period           

Parent Signature                                                         Date