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:

Relationship: ___________________

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 _____________________________

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