Roberta Jean Molyneux-Davis
The School of the Art Institute of Chicago
Department of Art Education
Master of Arts in Art Education Program
Participant Consent Form
I, ________________________________________, agree to participate in an action based research project being conducted by Roberta Jean Molyneux-Davis, in partial fulfillment of the degree requirements for the Master of Arts in Art Education at the School of the Art Institute of Chicago. The research is focusing on how viewers interact within the democratic educational space of public art in a community.
I understand the nature of this study as described by Roberta Jean Molyneux-Davis. I understand that I may choose to withdraw my participation from the project at any point. I understand that my identity will be protected, and my face will not appear in the final project, though my voice may be used as part of the final audio/visual component of the project.
I agree to allow (initial all that apply):
___ video recording
of my participation.
I understand that it may be (initial to indicate consent):
___ published on Tagwhat, a location-based mobile application.
I also release the use of my participation for (initial to indicate consent):
___ publicizing and
___ promoting the research and
___ release this material for broadcast purposes without monetary compensation.
If I have any questions about my rights as a participant, I will contact Drea Howenstein, Department Director, email@example.com, 312.629.6100; or Adam Greteman, firstname.lastname@example.org.
If you are interested in viewing the final thesis or documentary, please provide your email address: