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Media Form

TEACHER NAME:*

SCHOOL NAME:*

Title of Media:*

Type and Description of Media:*

To Be Used in Which Course/Subject:*

Grade Level:*

Length of Media:*

Dates to be used from:*

Select Date

Dates to be used to:*

Select Date

Portion of video to be used:*

Reason for use:*

How will this support the content standard?

Where was the media acquired?:*

Is Parent/Guardian permission required before students view this media?:*

Has the media been pre-viewed by the teacher?:*

Teacher Email Address:*

Understanding of Copyright Rules:

I'm aware of the copyright rules and this use complies with the copyright rules. I understand that I may be held personally responsible for copyright infringements. To complete this form you have to click 'I Agree' below.

I Do Not Agree
I AGREE

SubjectModeratorEmail:

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