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As part of the NDEC meeting it was decided that we might share our release form, contracts, etc that are used to inform research particpants and limit or control the use of our materials. To that end I have begun, by publishing a few of the release forms that I have used in the past. Please be sure to read the history introduction on each.--Raul Zaritsky

History of the Chicago Area

Violence Prevention Project and our Media Form

This project was developed by the trauma surgeons of Cook County Hospital and Raul Zaritsky working as an independent film producer. Funded by the Chicago Community Trust, we are in the beginning stages of developing a curriculum for K-7. To provide material for discussion, we taped stories from various children.

 This form was developed with legal consultation. The Chicago Area Violence Prevention Project used it as a consent form for children who would be filmed telling us stories about guns and violence in their lives. It is in two pages; the first is a short description of the project and the second is a consent form to be returned to us by parents. In addition to these forms, the project also was required to get consent from the relevant parties at the Chicago Public Schools.

Media Release Form CAVPP

Dear Parents,

 The trauma professionals of Cook Country, especially those from Cook County Hospital are producing a new curriculum with the help of your school. This curriculum will focus on anti-violence issues. We are attempting to make the curriculum age appropriate and culturally specific. Our simple idea is to use volunteer trauma staff to implement this program in the schools.

 Along with a committed staff, and in cooperation with your school, this project will be using a number of short films and video tape recording and playback to enhance the educational experience. Also we will be using some medical devices like splints and crutches to simulate what happens when one is injured.

 We will begin this program in your childŐs classroom the first few weeks of June and again in the fall. We would like your child to be a part of this program. To be included, each child must have a signed consent form. Please sign the enclosed form and return it with your child to their teacher as soon as possible.

 If you have any question concerning this program, please contact Mr. William Weber RN., trauma coordinator, at xxxxxx. Thank you for your cooperation in this exciting opportunity.

Sincerely,Dr. SurgeonDepartment of Trauma, Cook County Hospital


I, ____________________________, on behalf of my heirs successors and assigns, in consideration of my desire for participation in the production of an educational video tape based curriculum, consent to the participation of my child or ward and authorize Dr. Kim Joseph and Raul A. Zaritsky and the staff of Z.I. Ltd., and all of its heirs successors and assigns, to use the recorded image voice and statements of ______________________________(childŐs name) in programs for use in all manner of educational media, to further these public educational goals.

 I acknowledge that the Chicago Committee on Trauma is the sole owner of all rights in and to the Programs and Materials produced and the recording thereof for all purposes and that you have the right, among other things, to use the Programs produced an unlimited number of times in any educational situation or any distribution of the Program.

Additionally, and on behalf of my heirs successors and assigns, I hold Raul A. Zaritsky, Z.I. Ltd. Cook County Hospital, the Chicago Committe on Trauma and all of their heirs successors and assigns, harmless from any and all claims damages and causes of action, of what-so-ever nature, and agree to indemnify them of and from any and all such claims demands and causes of action which may arise from, out of, or by reason of my participation in this recording. Signed on this date:

I assert that I am the legal parent or Guardian for ____________________________________ signed name (please print) address date phone