AUDIO AND VIDEO RECORDING CONSENT AND RELEASE FORM FOR TEACHER EDUCATION INTERNS at templateshunter

This year (school name) is hosting teaching intern, (intern name), from Plymouth State University, under the mentorship of an experienced teacher and a Plymouth State University supervisor. As part of the teaching internship, teaching interns must demonstrate and reflect on what they know and are able to do as teachers by fulfilling the requirements of the New Hampshire Teacher Candidate Assessment of Performance (NHTCAP).
The NHTCAP requires teacher interns to examine lesson plans, assessment, and instruction, which include audio- video recording teacher candidates, to assess their expertise and effectiveness.  This requirement is the result of a proactive approach to current educational trends toward accountability and increasing the rigor of teacher preparation, and has the full endorsement of New Hampshire’s Commissioner of Education and State Board of Education.
It is crucial that we protect the privacy rights of our students and their families and respect the conditions under which schools allow us access to their classrooms and students. For this reason, we seek permission from families to include their child in the audio-video recorded segments of instruction. The permission granted for videos/photos is predicated on limited use; that is, to be shared solely between the interns, mentor teacher, supervisor, PSU faculty, and, in some cases, other New Hampshire university teacher preparation faculty for purposes of each intern’s instructional requirements, assessment, and professional development. Interns will be able to use these images to assess their own instruction but will require permission from the parent/guardian of the student captured in these images. The use of such recordings is strictly limited to the context of the intern coursework requirements and assessment under the NH TCAP. At no time will any of these video recordings or photos be posted on public media, social media, social networking, or any publically accessible Internet sites.
Please indicate your preference and sign below:
____I do give my permission for [name of intern], the teaching intern in my child’s classroom at (school name) to include my child in audio and/or video record segments of her/his classroom instruction.
____I do not give my permission for [name of intern], the teaching intern in my child’s classroom at (name of the school), to include my child in audio and/or video record segments of her/his classroom instruction. Accordingly, any videoing that occurs in the classroom on behalf of the intern will be done in a way that ensures my child will not be visible or identifiable.
I have read and fully understand the terms of this release.
Name of student (print or type)_________________________________________________
Name of Parent/Guardian (print or type): _________________________________________
Parent/Guardian Signature: ___________________________________________________
Date: _______________
Please sign and return this form to your child’s classroom teacher. If you have any questions about this form or the requirements described above, please contact Dr. Megan Birch, Director of Educator Preparation at PSU (603-535-2860 or mlbirch@plymouth.edu) and/or (principal name), Principal, at (school name).
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