Consent Form Template for [State Name] Residents
This consent form is designed to comply with the relevant laws of [State Name]. Please fill in the required information and ensure that all entries are accurate.
Participant Information:
- Full Name: ________________________________________
- Date of Birth: _____________________________________
- Email Address: _____________________________________
- Phone Number: _____________________________________
- Address: ___________________________________________
Consent Information:
By signing this form, you allow [Insert Name of Organization/Individual] to:
- Collect and use your personal information for the purposes of [insert specific purpose, e.g., research, treatment, etc.].
- Share your information with [insert names of third parties if applicable, e.g., medical professionals, research teams, etc.].
- Contact you regarding [insert reason for contact, e.g., follow-up, updates, etc.].
I understand that I have the right to withdraw my consent at any time by contacting [insert contact information].
Agreement:
By signing below, I agree that I have read this consent form and fully understand its contents. I voluntarily consent to the collection and use of my information as described above.
Signature: __________________________________________
Date: _______________________________________________
Guardian Consent (if applicable):
If the participant is under 18 years of age, a parent or legal guardian must also sign below.
Guardian Name: ______________________________________
Guardian Signature: ___________________________________
Date: _______________________________________________