Child Assent Form
This form is designed to collect assent from children regarding their participation in research or activities. Please read the information below carefully before signing.
Child's Full Name
First Name
Last Name
Child's Age
Parent/Guardian's Full Name
First Name
Last Name
Parent/Guardian's Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
I understand that I am being asked to participate in a research study. I have been informed about what the study is about and what my participation involves. I understand that my participation is voluntary and that I can choose not to participate or to stop participating at any time.
I have been told that my answers will be kept private and that my identity will not be revealed in any reports of the study.
I understand that I can ask questions about the study at any time, and that I can talk to my parent/guardian about my decision to participate.
Do you agree to participate in this study?
Yes
No
If you have any questions about this form or the study, please contact:
Child's Signature
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian's Signature
Submit
Should be Empty: