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Sample Student Work Sharing Permission Form

About This Form

There are many situations where it can be helpful to provide examples of student work (videos, papers, projects, etc.) in courses, workshops, and presentations. You are under no obligation to provide permission to use your work, and your decision will have no influence on your course grades. If you are willing to give permission to use your work as an example, please complete the following form and return it to your instructor. By sharing your work, you are helping other students to better understand the assignment expectations. If this is group-work, permission will need to be obtained from everyone in the group.

Statement of Permission

I ____________________________ (name of student) provide __________________________ (name of instructor) permission to use and adapt all or part of the following work as an example in academic courses, workshops, and presentations.

Student Work Details

Course Number and Title (if applicable):

Title of Work:

Phone (optional):

E-mail Address:

Select one of the following by adding your initials in the space on the left:

______ You may use my first and last name to identify the creator of the work.

______ You may use my first name only to identify the creator of the work.

______ You may use my work, but do not list my name.

Additional Instructions (e.g., if you would like identifiable details like names of people changed within your work, if you would like only specific sections of the work to be used, etc.)




Signature: _________________________________________________

Date: ______________

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