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Sample Consent Letter

I hereby consent to myself / my child (whose name is _______________________ ) being video


taped, audio taped, tested, and/or observed.

I understand that:

(a) any information gathered (as noted above) will be used only for educational purposes and
that this information may be shared with the tester's course instructor(s), with other
legitimate professional and consultants and possibly with graduate students registered in the
course, Education 6709.

(b) if the named child is tested at the request of the counselor or another person in his or her
school, where appropriate, test results may be given to the school for appropriate educational
issues.

(c) that all information gathered is to be kept strictly confidential and to be used only for
purposes stated.

(d) any video or audio recordings made of me or my child will be erased on or before December
31, 1998 unless my written consent has been given.

(e) I have the right to revoke my permission at any time.

_________________________________ __________________________________
Signature of Consenting Parent/Guardian Signature of Witness-Optional

_________________________________ __________________________________
Printed Name of Consenting Party Printed Name of Witness

_________________________________ __________________________________
Signature of Tester Date