Full Name of Person Interviewed (print):________________________________________

Address:________________________________________________________________

Phone: (      )_____________________________________________________________

Place of Interview (include Parish):____________________________________________

Name of Interviewer (print):__________________________________________________

Interviewer's School: __________________________Date of Interview:_______________

I understand that this interview and any photographs, audio recording, or video recording are part of scholarly research by students at the school named above. I give permission for the following (check all that apply):

______May be used for educational purposes and research at the above school
______May include my name
______May be included in a school publication or exhibit
______May be included in another educational, nonprofit publication or exhibit
______May be used but DO NOT include my name
______May be deposited in a school, parish, or state archive
______Other (explain)

_______________________________    ___________________
Signature of Interviewee                                Date

_______________________________    ___________________
Signature of Parent or Guardian if                Date
Interviewee Is a Minor

For a PDF of this page click here.