Video Release Form printable pdf download

Research title

Researcher’s Name

(Directions: Include this form in your protocol submission if you will be videotaping

participants. If you are videotaping children, you will need to have their parents’

permission. Please include only those uses of the video that you intend. All are

included here to give you an idea of how you might want to use the video in the

future. If you think that someday you might put this up on a web site, ask permission

now, rather than having to go back to the participants later. If you have no intention

of using it on a web site, don’t include that option on this form. If you include #4,

specify what level classroom—elementary/middle/high school/college, and for what

purpose. Delete these instructions before turning in your finished document.)

Video Release Form

As part of this project, I will be making videotape recordings of you (or your child)

during your participation in the research. Please indicate what uses of these

videotapes you are willing to permit, by putting your initials next to the uses you agree

to, and signing the form at the end. This choice is completely up to you. I will only

use the videotapes in ways that you agree to. In any use of the tapes, you (or your

child) will not be identified by name.

1. _______ The videotapes can be studied by the research team for use in the

research project.

2. _______ The videotapes can be used for scientific publications.

3. _______ The videotapes can be shown at scientific conferences or meetings.

4. _______ The videotapes can be shown in classrooms to students.

5. _______ The videotapes can be shown in public presentations to non-scientific

groups.

6. _______ The videotapes can be used on television or the audio portion can be

used on radio.

7. _______ The videotapes can be posted to a web site.

I have read the above descriptions and give my consent for the use of the

videotapes as indicated by my initials above.

Name_____________________________________________________________

___________________________________________ _______________________

(Signature)

(Date)

Video Release Form