Learning Design Case Publication Consent Form
Submit your case details and provide consent for publication of your learning design case.
Contributor Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Affiliation (Institution/Organization)
*
Role in the Project (e.g., Instructor, Designer, Student)
*
Please Select
Instructor
Designer
Student
Administrator
Other
Learning Design Case Title
*
Brief Description of the Learning Design Case
*
Names and Roles of Additional Contributors (if any)
Do you consent to the publication of your learning design case, including descriptions, images, and materials you provide, on the designated platform?
*
Yes, I consent.
No, I do not consent.
Do you wish your case to be published anonymously?
*
No, publish with my name and details.
Yes, publish anonymously (do not display my name/affiliation).
Upload any images, materials, or supporting documents to be included with your case (optional)
Upload a File
Drag and drop files here
Choose a file
Cancel
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I confirm that I have the rights to share all materials and media submitted and grant permission for their publication as part of the learning design case.
*
I agree and confirm the above statement.
Please specify any limitations or restrictions on the use or distribution of your learning design case (optional)
Date of Consent
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature (please sign below to indicate your consent)
*
Submit Consent
Submit Consent
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