Name: _______________________ Code: _____ _____ _____ _____
Sports and other extracurricular activities you will be involved in this year:
Any close family members who are involved in psychology or related fields:
Field: Psychology ___ Psychiatry ___ Social Work ___ Other: ______________
I have read Diane Guido's disclosure document, and I understand the expectations for the course, as well as my responsibilities.
Signed ________________________________________________________ Date _____________________________