Video Presentation Permission Form
Mary O'Dell

Video Broadcast Permission Form

Willow High School



Teacher’s Name: __________________________ Date: __________



Name of Video:____________________________________________

Video rating - G PG PG-13 R NR (not rated) Unknown

(You must have signed parental permission slips for ratings above PG-13)

What alternate activity will be provided for any students who do not have parental permission?

How was the video acquired?

_____ taped from TV/Cable date(_______________)

_____ rented (I have permission to show it.)

_____ owned by the school

_____ teacher owned

_____ other (explain) ____________________________________

Length of video ____________ Date(s) to be shown ________ Blocks(s) you will be showing this video - 1st 2nd 3rd 4th (Circle all that apply)

What essential question(s) are you studying and how will this video relate to them?

What follow-up activities are planned for the video? (1 is required)

Teacher’s Signature _______________________________________

The teacher signed above accepts responsibility for copyright compliance for broadcasting this video.



_____________________________________________
Principal’s signature (or designee)

_____________________________________________
Date

Approval is required for materials not owned by the school

Approved __________ Denied __________

1)

What essential question(s) are you studying and how will this video relate to them?

What follow-up activities are planned for the video? (1 is required)

Based on the form, what inference can you make from the comparison of these two questions?

A)
Video presentations require planning.


B)
Video presentations are required at least one time.


C)
Videos presentations are used during free time and after tests.


D)
It is essential to ask students questions about each video presentation.


2)
Which is a valid conclusion that can be drawn from reading this form?

A)
Teachers can show videos to their students at any time for any reason at all.


B)
Videos are great instructional aides that should be utilized by all teachers.


C)
Teachers must justify every use of video in their classroom probably due to past video misuse.


D)
Television and videos are limited as teaching tools and are not as effective as simply face-to-face teaching.