Student Consent Form (Page 3 of 3) in pdf

Student Consent Form Page 3

Mayerson A cademy

Page 3 o f 3

If you decide to take part, you are free to stop at any time. If you wish to stop

taking part in the study, please discuss with your parent or guardian and ask

them to contact Mark Linkins to have you removed from the study or ask Mark

Linkins or a study staff member yourself.

WHOM SHOULD I CONTACT IF I HAVE QUESTIONS?

You may ask any questions about the study at any time. If you have questions

about the study after you leave today you should contact the Principal

Investigator at the telephone number or email address listed on the first page of

this form or ask your parents or guardian to contact the investigator for you.

Please sign this form and give it to your parent or guardian. You parent or

guardian also has a permission form that must be signed and returned. He or she

will return your form, along with the parent permission form.

By signing your name below you indicate the following:

1. You have read this consent form.

2. You have had an opportunity to ask any questions about your participation

in this research.

3. You are voluntarily agreeing to participate in the study.

If you decide to participate and your parent or guardian provides permission,

you/your parent or guardian will receive a copy of this signed and dated form for

your records. You will also be given your personal classified ID number.

Name of Participant (please print):______________________________

______________________________

____________

Signature of Participant

Date

Mark Linkins

Chesapeake IRB Approved Version 11 Feb 2014

Student Consent Form Page 3