Parent / Legal Guardian Consent Form printable pdf download

PARENT / LEGAL GUARDIAN CONSENT FORM

(Note that the information in italics will need to be completed by the researcher.)

PARENT / LEGAL GUARDIAN CONSENT FORM

My signature below indicates that I have read the information provided and have decided to allow my

child, ___________________________________ (print student’s name), to participate in the project

titled, “name of project” to be conducted at my child’s school.

I agree to the conditions listed below with the understanding that I may withdraw my child from the

project at any time, and that my child may choose not to answer any questions that he/she does not

want to answer.

1. Please describe what you will ask the student to do, and how much time you predict will be

involved in participation, and the length of the study (how many times will data be collected).

2. Please describe all data you will collect from student records, such as test scores, attendance

data, etc. and what you will do with this data.

3. If you are requesting access to free/reduced price meal eligibility status, please state that you

are requesting such access and include a statement indicating that the failure to allow access to

this information will not affect eligibility for or participation in Child Nutrition Programs.

4. The following statement will need to be included “The results of my student’s participation in

this project will be kept confidential unless I give prior written consent.” Please state here how

the identity of participants will be protected and who will have access to the project data.

5. Please describe here in what form or forms the data you collect will be reported or otherwise

shared.

6. Please state here any risks or inconveniences that participants might incur. If there are none,

include a statement so indicating. If there are risks, indicate that the risks are and what

precautions you will take to protect participants. Describe the benefits of participating in the

study and the compensation, if any, to participants.

7. My consent is optional and voluntary. My decision whether or not to allow my child to

participate will not prejudice my present or future relations with (your institution’s name here)

or my child’s school or teacher. If I decide to let my child participate, I am free to discontinue

participation at any time without prejudice. To the extent that my child may be identified, if I

withdraw my student from the project, my student’s information will be removed from the

project results.

Parent / Legal Guardian Consent Form