Consent Form

Veronica Marina Fazzio Welf

Social sculpture participants’consent form:

By signing this consent form, I_________________________ am giving Veronica Marina Fazzio Welf (VMFW) permission to record, video and photograph the performance I’m participating in. I authorize VMFW to potentially quote me for her PhD research and use the video and photographs where my image and/or voice appears.

By checking the 1^st and 2^nd box below, I choose to authorize VMFW whether or not to write my name on the material if needed.

At the date of this form, I am receiving information on how to access to the material after editing, which can take from 7 to 30 days from the date of the session.

In the case I decide to withdraw from the writings and/or video and/or photographs and/or recordings I must give VMFW 30 days notice and must be within 90 days from the session date, at that point any and all parts where I appear on image or voice will be destroyed.

At the moment of this signature VMFW provided me with her blog information (where all her research material is collected), her phone number, email and her studio address.

1-___I’m willing to participate in the social sculpture but I don’t want to be identified by name in VMFW’s research.

2-___I’m willing to be identified by first and/or last names (delete as applicable) in VMFW’s research.

Name:

Signing for:

________________________

Date & Signature