Parent or Guardian Consent Form

If you have any questions about any item on this consent form, I am happy to discuss it with you. I am available every day in the classroom before and after school, and during the school day. You also are invited to call me anytime at __________________, or email me at _____________________.

Student’s Name ___________________________  School _________________________

Teacher’s Name: __________________________ Teacher:________________________

Please check the statements which apply to your consent.

I grant permission for my child’s student teacher… 

o yes  o  no

To take and use school photographs which include my child for the purposes of self-study and portfolio evidence.

o yes  o no

To take and use school videos of my child engaged in various classroom activities while I am my teaching.

o yes  o no

o not applicable

I ask that my child’s face be blurred or deleted in all photographs and/or videos for which I have granted consent.

o yes  o  no

To tape-record classroom conversations and discussions which include my child. No one but the student teacher will have access to these recordings, and all identifying information will be removed from any transcriptions.

o yes  o  no

To collect samples of my child’s academic work, from which his or her name or any other identifying information will be removed.

Further, I understand that…

o yes  o  no

My child will not be identified by name, classroom, or school in any reports, presentations, or publications by the student teacher. 

o yes  o  no

o not applicable

Permission from my child will be sought each time the student teacher wishes to photograph, video or tape record my child, or his or her academic work is used for the student teacher’s purposes beyond ordinary classroom activities and requirements. My child can refuse to have his or photo taken, be videotaped or recorded, or provide samples of his or her academic work for purposes other than ordinary classroom activities and requirements without any negative consequences.

o yes  o  no

o not applicable

My child’s participation in the student teacher’s professional development projects is voluntary, and my child can refuse to participate, or withdraw from participation at any point without any negative consequences.

o yes  o  no

 o not applicable (consent not given)

I may withdraw my consent for my child’s participation in the student teacher’s professional development projects at any time by notifying my child’s teacher and the student teacher named below, without any negative consequences.

o yes  o  no

o not applicable (consent not given)

I will be invited to the Illinois Wesleyan University Educational Studies Inquiry Conference in April 2010 to learn how the student teacher has made use of the above documentation for which I have granted consent.

Parent / Guardian name (please print):______________________________________

Signature of parent/guardian __________________________   Date" ______________