CONSENT FORM FOR PARTICIPATION IN THE
"BEAGLE EPILEPSY RESEARCH PROJECT"

DOG’s REG. NAME:___________________________

The undersigned, who is the owner or co-owner (or owners or co-owners) of the above Beagle, such Beagle having been born on ______________ and having been issued #___________________ as it AKC registration number, agrees to participate in the above "Epilepsy Project" (as more fully defined below). The undersigned acknowleges that participation includes cooperation on the following:

1. Submission of copies of (a) the above Beagle’s AKC registration certificate and 4-generation pedigree (or, alternatively, written authorization to the Epilepsy Project to obtain additional pedigree information about the above Beagle from the AKC) and (b) completed litter information forms and lists with respect to breedings of the above Beagle;
2. Transmission to the Epilepsy Project of blood and/or tissue samples (with tissue samples, however, only to be submitted after a dog is deceased);
3. Completion of a general health survey on the above Beagle and/or participation in a telephone interview (lasting approximately 20 minutes); and
4. Granting permission for the Epilepsy Project to contact the above Beagle’s veterinarian regarding its health history.

The undersigned acknowledges his, her, or their understanding that the "Beagle Epilepsy Research Project" (sometimes herein "Epilepsy Project") entails research to be carried out by the principal investigators at the University of Minnesota, pursuant to the research study that is more fully described on the reverse side of this Consent Form, as well as that the study has been approved by, and is being funded by The American Kennel Club Canine Health Foundation. It is agreed that this "Epilepsy Project" may be expanded and/or supplemented in the future to include other research studies relative to epilepsy and that this Consent Form constitutes the undersigned’s approval of utilization of all submitted information provided each study is approved by the National Beagle Club of America and/or the AKC Canine Health Foundation.
The undersigned further acknowledges that information provided to this "Epilepsy Project" will be made available solely to (a) the principal investigators for the study described on the reverse side of this Consent Form and their staffs (as well as, possibly, scientific investigators involved in epilepsy studies approved in the future by the AKC Canine Health Foundation and/or the National Beagle Club of America) and (b) persons associated with the National Beagle Club of America who are working on this project and who are specifically approved to receive such information by the Beagle Club of America Board of Directors. It is also understood that any publication for the public, resulting from this Epilepsy Project, will refer to individual dogs solely by an anonymous code.

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Signature                                  (Date)             _______________________________________
                                                                                                  Address

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           Name (Print)                                                                               Telephone number

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Signature                                  (Date)             _______________________________________
                                                                                                  Address

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           Name (Print)                                                                               Telephone number