Darien Public Schools

Educational Access Video Program Review Form

Name of Tape/Program __________________________________________________________

Exact Broadcast Length - Minutes/Seconds _____________ Is the material date sensitive? _____

Requested START and END dates to be broadcast ________________Thru_________________

Name of responsible party (Admin, Teacher, Coach, etc.) _______________________________

Please Print

Describe specific broadcast content _________________________________________________

______________________________________________________________________________

Consent forms for every recognizable student have been collected and checked (circle).
Yes No

This program has been viewed in its entirety by the responsible party and I verify that it complies with all requirements listed in the Board Policy #JB3 and Administrative procedures a through k for school sponsored information media.

Signature of such Responsible Party ____________________________ Date______________

School Administrator’s Signature_______________________________ Date______________

Signature of Staff Programming the Tape for Broadcast _______________________________

The completed, signed, original copy of this form MUST be filed in the logbook of the Darien Public Schools Access Channel, prior to broadcasting of the program.