(Form 5: omit this label)

Primary Investigator: [Insert the name of the professor/supervisor]

Student Researcher(s):

Title of Project:
On __________, I was informed that the data derived from my child’s participation in this study may be held for future use. I agree that these data may be stored and reanalyzed or otherwise combined with other data at a later date after the specific time period defined by this study.

____________________________
Printed Name of Participant


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Printed Name of Parent/Legal Guardian

____________________________
Signature of Parent/Legal Guardian

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Date