BreakThru Participant Informed Consent to Use Image

I, the undersigned, do hereby consent to the use by the research project titled “The Georgia STEM Accessibility Alliance (BreakThru)” conducted by Noel Gregg, Ph.D. Institute for Interdisciplinary Research in Education and Human Development, University of Georgia (706-254-2334) and Robert Todd, CATEA, GaTech (404-894-9865) of my image, voice, or both either in whole or in part, for the purposes of reporting, advertising, or recruiting, on behalf of the BreakThru Project.

I understand that my participation is voluntary. I can refuse to participate or stop taking part at any time without giving reason and without penalty or loss of benefits to which I am otherwise entitled. I can ask to have all of the information about me returned to me, removed from the research records, or destroyed without penalty or loss of benefits to which I am otherwise entitled. In addition, I waive all claims to compensation or damages based on the use of my image or voice, or both, by the BreakThru Project.

I agree that all such portraits, pictures, photographs, video and audio recordings and any reproductions thereof, and all plates, negatives, recording tape, and digital files shall remain the property of the University of Georgia’s BreakThru Project, unless otherwise noted. I understand that this consent is perpetual across the 5 years of the project or until my participation in the project has ended.

My signature below confirms that conditions of my consent to be videotaped and photographed have been explained to me, and I understand the following:

• I can withdraw from the study and my permission at any time.
• Video/photo will be edited by BreakThru staff.
• Video/photo will be posted on the GSAA website and affiliate websites and the GSAA virtual world.
• I can view video/photo and discuss its contents with project staff.

The benefits for me are that I will be providing information on the use of virtual worlds and social networks for educational purposes. My feedback will shape a model that can be implemented in other school systems across the nation.

No risk or harm is expected. I understand that the video will be used for research and educational purposes only and that my image will not be used for any other purpose. Employment or grades at my school or institution will not be affected by my decision to participate or not participate in the research.

I understand that I am agreeing by my signature on this form for BreakThru to use my image and understand that I will receive a signed copy of this consent form for my records.