Authorization for reproduction (circle options in bold below)

Name:

Course:

Semester/Year:

I hereby DO / DO NOT authorize the use of my work for purposes of research or teaching in the future.

If it is so used, my name should be LEFT ON / KEPT OFF

Signature:

Date:

Please mark with an asterisk * specific parts of your CBL project that you would like to share with the CBL Office and/or the Community Organization at which you volunteered