Pediatric Research Study Participation Agreement

Study Information

Study Title: [INSERT STUDY TITLE] Principal Investigator: [INSERT NAME], MD Institution: [INSERT INSTITUTION NAME] IRB Protocol Number: [INSERT NUMBER]

Child Participant Information

Child's Full Name: ________________________ Date of Birth: //______ Medical Record Number: ___________________

Parent/Legal Guardian Information

Name: ________________________ Relationship to Child: ________________ Contact Phone: ____________________ Email: ___________________________

Consent Declaration

I, the undersigned parent/legal guardian, voluntarily consent to my child's participation in the above-mentioned research study. I acknowledge that:

1. I have read and understood the study information sheet dated [INSERT DATE]
2. The study procedures, risks, and benefits have been explained to me
3. I have had the opportunity to ask questions and received satisfactory answers
4. I understand that participation is voluntary and can be withdrawn at any time
5. I have been informed about how my child's personal data will be protected

Authorization for Data Collection

I authorize the research team to:

• Collect and analyze my child's medical information
• Share de-identified data with other researchers
• Store study-related information in secure databases
• Contact me for follow-up assessments

Signatures

Parent/Legal Guardian Signature: ___________________ Date: //______

Witness Name: ________________________ Witness Signature: ____________________ Date: //______

Investigator Name: ____________________ Investigator Signature: _________________ Date: //______

Contact Information

Study Coordinator: [INSERT NAME] Phone: [INSERT PHONE] Email: [INSERT EMAIL]

IRB Contact: [INSERT CONTACT] Emergency Contact: [INSERT CONTACT]