Consent Form for Archiving Student Research Assignments
Dr. John Lutz, an associate professor in the History Department at the University of Victoria has created an archive
and he would like to ask permission to place the research assignment I did for a course I have finished, History 318 –
The Social History of the Automobile – in this archives which will eventually be housed with the University of
Victoria Special Collections and Archives. If you check the box below it will also be part of an on-line archives.
I have already received my grade for this course and I am under no obligation to agree to this use of the material.
Dr. Lutz believes that the information obtained in this research is original and will be very valuable for future
generations interested in how the automobile was used by living generations and how it affected our lives. There are
few other sources for the kind of information in my research paper so it is a rare and valuable resource for the future.
If are willing to give permission for this material to be saved for future historians you may place some conditions on
its use if you like. Some may of the conditions include:
I would like personal information including names removed from the paper and pseudonyms used.
The research is to remain sealed and unavailable for research use for a period of _________ years.
I agree to allow the research assignment to be included in a website archives of family auto-biographies
developed by Dr. Lutz and accessible from http://web.uvic.ca/~jlutz
I would like to place the following conditions on the use of the material in the research paper:
I agree to allow the material collected for the research assignment to be archived by Dr. Lutz and made available to
future researchers under the conditions specified above.
Name of Participant Signature Date
Name of Student Signature Date
A copy of this consent will be left with you, and a copy will be taken by Dr.Lutz. Please contact Dr. Lutz with any
questions you may have at 250-721-7392 or email@example.com.