Subject: (name of person being interviewed)
___________________________________________
Address: ___________________________________
I hereby give ________________________________
(name of interviewer) permission
to use the information from the interview given on ____________________(date of interview)
The information may be used for educational purposes.
My name may ____, may not ____
(check one) be used.
Signature
___________________________________________
Date _______________________________________
Interviewer's Name __________________________
Address ____________________________________