Participant Form for Adult Class

Description: You are invited to participate in a confidential study on the long term impacts of The Conflict Center’s conflict and anger management classes. From the information collected and studied in this project we hope to learn more about the long term impact of our classes.
Procedures: With your permission, we would like to collect survey data from you approximately three times in the next two years after the completion of the class. This would require temporarily associating your name and contact information with your survey data.
Risks and Benefits: There are no anticipated risks associated with this study. We cannot guarantee or promise that you will receive any benefits from this study.
Time Involvement: Your participation in this study will require about 5 minutes of time from you at approximately three times in the next two years.
Payments: You will not be paid to participate in this study.
Participants Rights: Your decision whether or not to participate in this study will not affect your completion of our classes. If you have read this form and have decided to participate in this project, please understand that your participation is voluntary and you have the right to discontinue participation at any time.
Signature of participant: I have read this entire form, or it has been read to me, and I understand it completely. All of my questions regarding this form have been answered to my complete satisfaction. I agree to participate in this study.

I grant to The Conflict Center the right to take photographs, video images, or digital recordings of me and my family in connection with the above-identified event. I authorize The Conflict Center, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I waive any rights, claims, or interest I may have to control the use of my identity or likeness in whatever media used.
I agree that The Conflict Center may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content. I agree to hold The Conflict Center harmless from any liability arising from the use of my image as described above.