I understand that I have been asked to participate in a study about __________________

I will be asked to ________________________________________________, which will take

about _______________ minutes. I understand that I do not have to participate. If I do participate, I can quit at any time. I also understand that I do not have to answer any questions I don't want to answer or do anything I don't want to do.

My parents, teachers, or anyone else will not know what I have said or done in the study. No one but the researchers will know.

This study is being done by _____________________________________ (Name of

researcher) at Bryn Mawr College. His/her phone number is _______________________.

If I have any questions or concerns about the study, I can call and ask him/her about them.

When I sign my name, this means that I agree to participate in the study and that all of my questions have been answered. I have also been given a copy of this form.

Name____________________________ Signature_______________________

Name of Witness _______________________

Witness Signature_______________________ Date____________________