100 A Views on Diversity

Argosy University Online Program

PSY312 Diversity

AUTHORIZATION TO RELEASE INFORMATION

I, (name of interviewee) ______________________________, (hereinafter “Interviewee”) hereby authorize (name of student-interviewer) ___________________ (hereinafter “Student”) to disclose information about the interviewee’s complete developmental history as part of the Student’s classroom final project for the PSY 312 Diversity program which the Student is currently enrolled in at Argosy University Online Program.

I understand that I have a right to receive a copy of this authorization. I understand that any cancellation or modification of this authorization must be in writing. I understand that I have the right to revoke this authorization at any time unless the Student has taken action in reliance upon it. And, I also understand that such revocation must be in writing and received by the Student at (Student’s email address) _________________________ to be effective.

This disclosure of information authorized by Interviewee is limited only for the following purpose: to provide Student with background to complete the Final Project in PSY 312 Diversity at Argosy University.

The Student shall not condition the interview and information gathering upon Interviewee signing this authorization and Interviewee has the right to refuse to sign this form.

This authorization shall remain valid until: _____________________________________(Last Day of PSY 312 Class)

Interviewee’s signature:__________________________________ Date:___________________

Student’s signature: _____________________________ Date: ___________________