Template For Consent / Assent Form printable pdf download

Template for Consent / Assent form to be used with participants who are minors

(NOTE: You must customize this template to fit your own study.)

Dear Parent or Guardian,

Hello. My name is____________, and I am conducting a study to learn about

____________. The purpose of this study is to __________. I would like to interview /

survey / test / observe / videotape / audiotape/ etc. your child. If your child does not want

to participate in any or all of this study, that is fine. Either you or they can ask to

withdraw from my study at any time. It is also important that you know that being part of

my study or deciding not to will have nothing to do with your child’s grade or school

standing in any way.

Please read the paragraph below and then indicate your decision by checking the box that

shows what you wish. Then sign below with your child, so that I know if you and your

child agree to let me methods of data collection. Cut and return the signed portion to me.

If you would like to call me and ask me anything about this, please do! My number is

XXX-XXXX.

Thank you,

Signature of researcher

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We agree to let name of researcher interview / survey / test / observe / videotape /

audiotape/ etc. our child. We understand that name of researcher is trying to learn more

about purpose of study. We understand that we can choose to not participate at any time,

even if we already started, and it will have nothing to do with our grade or studies. We

understand that anything that name of researcher watches / records / hears/ etc. is just for

him/her to learn more about purpose of study . No one at school except list people who

will review data will know what information he/she gathers. Name of researcher can

write about the children for his/her study, but he/she will not use their names or any other

information that could identify them.

No, we don’t agree to participate

Yes, we agree to participate

Parent or Guardian

Child

Sign your name ____________________

Print your name ____________________

Template For Consent / Assent Form