Parental Consent for Mitochondrial DNA Sequencing
In our next biotechnology experiment each student will isolate and make copies of a small section (440
base pairs) of their own mitochondrial DNA. We will then send this DNA sample to a company (Genewiz)
where it will be sequenced. The sequences (As,Ts,Gs,and Cs) will be posted to a data file via the
Internet so that students can access their sequence and compare their sequence to those of other
students, modern humans of different races (Europeans, Africans, Asians, American Indians), ancient
humans, Neandertals, other animals, plants, etc.
Student participation in this experiment raises real-life questions about the use of personal genetic data:
What is my DNA sample being used for? Can the information be used to tell me anything about my life
or risk for diseases? Can my data be linked personally to me?
There is consensus that a human DNA sample should be obtained only with the willing consent of the
donor, who understands the purpose for which the sample is being collected. Students have the option
to not participate in this experiment.
The DNA sample to be sequenced has no known relationship to any diseases. Students samples will be
assigned a number without using student names to ensure anonymity. Please circle your preference
below.

I give permission for my student’s mitochondrial DNA to be sequenced.

I do not want my student’s mitochondrial DNA to be sequenced.
Student’s Name ___________________________________________
Signature of Parent or Guardian _______________________________________________
If you have any questions, please call or email.
Home: 657-0985 School: 654-0640
email: scott.ward@wasatch .edu