PSA Consent Form

PSA Team Consent Form

The Academic Integrity PSA program provides Connecticut high school students the opportunity to promote the value of academic integrity. The Student Director should collect the necessary information and complete the following Consent Form for their team. This form should be submitted prior to creating a PSA.
Team members for the PSA consent to the following:
(1) The student has reviewed the judging criteria found in the Contest Handbook that is available on the contest webpage,
(2) If their PSA is judged to be a statewide winner, they are willing and available to attend the Celebration Dinner to recognize their work on Wednesday, May 6st 2020 at no meal cost to the student and two guests,
(3) The School for Ethical Education is permitted to use any photograph taken at the Celebration event as well as the student’s image, name and voice in the PSA, which may be posted across various online platforms,
(4) SEE is granted an unlimited license to use the PSA for any educational purpose and,
(5) Affirming that all the material in the PSA is original work and is not subject to any copyright restrictions.

School sponsors, participants and parents/guardians will receive a confirmation email from SEE after receipt of the PSA Consent Form.

* Indicates required field

Student Director's Name *

First

Last

Grade *

School Name *

PSA Title *

Faculty /Sponsor Name *

Faculty Email *

Student Director's Email *

Student Director's Phone Number *

Director's Parent/Guardian Name *

Parent/Guardian Email *

Please have the title of your PSA reflect it's content.
PSAs with generic titles will be subject to editorial changes.

Collaborators

Please list the first and last names of all the students that contributed in the creation of your PSA.
If only one student created and produced the PSA, place NA in the required boxes below. If more than five
contributed, please email ethics@ethicsed.org with balance of names, roles and email addresses.

Collaborators and their parents/guardian name and email address provided here affirm that they have read and consented to PSA Contest five statements noted on this form (above).

Collaborator 1 *

First

Last

Role *

Collaborator 1 Email *

Collaborator 1 Parent's Name *

Collaborator 1 Parent's Email *

Collaborator 2 *

First

Last

Role *

Collaborator 2 Email *

Collaborator 2 Parent's Name *

Collaborator 2 Parent's Email *

Collaborator 3 *

First

Last

Role *

Collaborator 3 Email *

Collaborator 3 Parent's Name *

Collaborator 3 Parent's Email *

Collaborator 4 *

First

Last

Role *

Collaborator 4 Email *

Collaborator 4 Parent's Name *

Collaborator 4 Parent's Email *

Collaborator 5 *

First

Last

Role *

Collaborator 5 Email *

Collaborator 5 Parent's Name *

Collaborator 5 Parent's Email *

Submit

Ethics in action creates character

PSA Team Consent Form

Hours

Telephone

Address