Interview Permission Form

I understand that the information I provide in this interview may be quoted in a short essay, poster, recording, or video that the student (named below) will write or produce for a school assignment on Forestland History, and that this production will be read by the teacher of this class at the school (named below), shared with the class involved with this assignment, and may be used for other educational purposes.  Any original recordings may be archived with an official repository for future educational purposes.

When my statements are quoted in this student's paper and/or class discussions, I would like (circle one):

A) to be quoted by name;

B) to be quoted as a private forest owner, rather than by my real name.

Date: ___________________________________________________________

Interviewee Signature: ______________________________________________

Name of Student Interviewer: _________________________________________

Name of School: __________________________________________________