Photo/Video Release

University of Nevada, Reno

Photo/Video Release Form for Research

Title of Study:

Translating cognitive neuroscience to inform the use of behavioral assessments in child development

Principal Investigator:

Ann M. Weber, Ph.D., Primary Investigator, (775) 682-7089

Co-Investigators:

Jacqueline Snow, Ph.D. (775) 682-8688

Lars Strother, Ph.D. (775) 384-7109

Study ID Number:

IRBNet ID: 1945003-1

Sponsor:

NIH COBRE

Video-recordings will be made of your child during your participation in this research project. Please indicate below how we may use video recordings and still images obtained from the video. Agreeing to allow recordings of you or your child to be used for research is completely voluntary and up to you. In any use of these images, your name will not be disclosed.

For all uses to which you agree, please initial in the spaces provided in the following table:

Initials Uses

1.  The images may be studied by the research team for this research project.

2. The images may be used for scientific publications.

3. The images may be used at meetings of scientists interested in the study of early childhood development, neuroscience, neuroimaging, and behavioral assessments.

4. The images may be used in classrooms to teach students about early childhood development, neuroscience, neuroimaging, and behavioral assessments.

5. The images may be used in public presentations to non-scientific groups.

6. The audio recording may be used on television and radio.

You have the right to request that the recording be stopped or erased at any time.

By signing below, you are agreeing that you have read the above description and give your consent for the uses of your images as indicated by your initials.

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Participant’s Name Printed

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Signature of Participant Date

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Signature of Person Obtaining Consent Date