_________________________________ has designed a project to meet

requirements in _____________________________ at Concordia University,

Wisconsin.  By signing this permission form, you are acknowledging that you

have been informed about the purpose of this study/project, the procedure, how

the data will be gathered, and how the data will be analyzed.  You have also

been assured that confidentiality of the gathered data will be maintained.  A

report of this study/project will be made available to you, if you request it.

I understand that my participation is strictly voluntary, and that I may withdraw

from participation at any time without consequence. 

__________________________________                         __________________

Signature                                                                                      Date

If, for any reason you have concerns about your treatment as a participant in this

study/project, please call the instructor of this course:

Professor Mary Frances Bernadette

Concordia University Wisconsin

Psychology Department

262.243.4515