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delete the brackets and these instructions) [Project title] Release Form for Use of Photograph/Videotape [Your name] [Supervisor’s name if applicable (e.g., thesis advisor)] Colorado College Department of [fill in department name] [Phone number of department secretary, beginning with “719”] [Your email address] Please print: Name of Participant: __________________________________________________ Address: ____________________________________________________________ I hereby give my permission to [your name] to use any photos or videotape material taken of myself during [his or her] research on [title of project]. The photos and videotape material will only be used for research purposes and for the presentation of the research. As with all research consent, I may at any time withdraw permission for photos or video footage of me to be used in this research project. [Provide the participant with a copy of this form.] Signature: ______________________________________ Date: ___________________