Date:

Dear Parent/Guardian:

I am a student at Appalachian State University, and I am working in your child's class as a student intern.  As a part of my classwork at ASU, I will be working one-on-one with your child, with your permission, to assess his/her learning.  If you agree to allow me to work with your child, I will be required to shoot videotape your child in various school settings, take photographs of your child, and audiotape discussions that I have with your child.

Any products that I create will be reviewed by my professors at Appalachian State University who will handle the material confidentially.  Please indicate below if it is permissible to include your child on videotape, in photographs and/or audiotape, and return this to me by _______________.(date)

Thank you for your cooperation and assistance.

Sincerely,

Student Name:_____________________

Check appropriate response:
____Yes, my child may be videotaped, audiotaped, or photographed.
____ No, my child may not be videotaped, audiotaped, or photographed.

Parent/Guardian signature: ____________________  Date: _____