February 7, 2007
Video Consent form for Students
My name is Sharon Walpole. I am a school-change researcher currently serving as Assistant Professor in the School of Education at the University of Delaware. I teach undergraduate and graduate courses in literacy development, instruction, and supervision at the university. I also provide extensive service to teachers in Delaware and in other states to support improved instruction.
The most powerful tool that I can use in my work with teachers is real examples of excellent instruction. I am requesting permission for myself and my research assistants to collect digital video tape of your child during instruction, to edit that tape to highlight specific examples of quality instruction, and to use those images in perpetuity to create various formats (including, but not limited to, web-based forms, DVDs, CDs and tapes) for our use in perpetuity during undergraduate, graduate, and in-service professional development. Neither you nor your child will be paid to appear in this video, and this video will not be sold.
This agreement is between you and the University of Delaware and provides permission for Sharon Walpole and her colleagues to use your child’s likeness and his or her original material or material which he or she has authority to use for the purpose of supporting teaching and learning.
If you have any questions, please contact my by phone (302) 831-2560 or email .
Print Student Name ____________________________________________
Sign Student Name ____________________________________________
Print Parent Name ____________________________________________
Sign Parent Name ____________________________________________
Date ____________________________________________