Consent Form Template [Guidance And Holding Text Are Shown

consent form template [guidance and holding text are shown in square brackets in this template. please delete or replace all such text.]

Consent Form Template
[Guidance and holding text are shown in square brackets in this
template. Please delete or replace all such text.]
[PLACE LOGOS HERE]
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[Name of Project / Activity]
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Family details
Parent name
Address
Postcode
Telephone
[Name of organisation] is undertaking a [name of project / activity]
to [describe aims / outcome of the project / activity]. We are asking
you to help with this [project / activity], by [what will be the
families input e.g. interview] and letting us analyse information
about [what information is being collected e.g. how a customer uses
services].
How will my information be used?
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The information that you provide about you and your family will be
used to [describe the purpose of collecting the information e.g. gain
an insight into services and what is important to families]
The [name the area] partnership, which includes organisations like [insert
area] Council, NHS [area], Police and Fire Services, is undertaking
this [research / activity] together. This means that it will be
necessary for the [area] Partnership to share information about you
and your family for the [research / activity].
Information that you provide to us will be recorded and stored
securely. We understand that some information may be sensitive and we
will keep your information confidential and use it only for the [name
project / activity]. The only exception to this is if you tell us
anything indicating that someone might be in danger; then we have a
responsibility to act on that information but we would not do this
without telling you and including you in the process.
Consent
I have read the information above and have had an opportunity to ask
questions about the [research / activity] and how my information will
be used. I understand the purpose of the [research /activity] and what
my participation involves.
I agree to take part in [describe what involvement the individual will
have e.g. an interview] and for the information I provide to be shared
with the [area] Partnership agencies and this in turn allows services
that I use to share information about me and my family for the purpose
of this [research / activity]. I understand that I need to inform the
other members of my family that I have given consent which will allow
them to opt out if they wish.
I understand that anonymised [information / research] about me and my
family may be published within the [project report / relevant document],
which may be published online and that published material from this [project
/ report] may be used and distributed for training and service design
and development.
I know that my participation is voluntary and that I can choose to
withdraw from the research at any point.
Parents name: _________________________________________ (print)
Signed: _________________________________________
Witness name: _________________________________________ (print)
Signed: _________________________________________
Date: ___________________