CONSENT FOR ONLINE SPECIAL EDUCATION AND RELATED SERVICES

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

HAWTHORNE COUNTRY DAY SCHOOL 2021-2022 SCHOOL YEAR

CONSENT FOR THE USE OF TELE-THERAPY AS A MODE OF INSTRUCTION DURING REMOTE OR HYBRID MODEL OF LEARNING

The consent form for the use of Tele-Therapy must be completed by the parent/guardian and submitted so Tele- therapy sessions can begin and/or continue.

Email *

Please Choose one: *

Preschool Westchester Program

Manhattan School Age

Westchester School Age

Child's Last Name: *

Child's First Name: *

Students DOB: *

YYYY

Phone Number # : *

Home School District *

NYC

Westchester

OTHER

Please check all that apply in accordance with my child's IEP *

Occupational Therapy

Physical Therapy

Speech Therapy

Counseling Therapy

Other:

Required

I understand and agree that neither I nor my child may re disclose or intentionally breach the confidentiality of the group or individual, special education, and/or related service sessions, nor in any way interfere with the ability of the teacher or provider to provide services in the online setting. I understand that if either myself or my child intentionally breach confidentiality, this could constitute a basis for discontinuing the provision of the service, in that form. I further understand that the Hawthorne Country Day School will make every reasonable effort to prevent the inadvertent disclosure of students’ personally identifiable information (PII) while services are being provided through various online mediums; however, I also acknowledge that the provision of services in this manner presents unique challenges and risks to maintaining confidentiality of PII, and that, notwithstanding those challenges and risks, I consent to my child receiving services in a group/individual setting through various online mediums *Please acknowledge below, that you have read this section. *

I have read this section

Required

Please Read and Check the Box *

Typing my name below I AM consenting to have my child’s Related services delivered using Tele-Therapy as a special education service delivery method. I understand that the Tele-Therapy services that my child will be receiving will fulfill the service mandate in my child’s Individualized Education Plan (IEP) for the time period that HCDS is operating remotely or hybrid.I understand that Tele-Therapy as a related service delivery method is only available during any time period the school is operating remotely or hybrid and that my child’s services will be delivered using the method(s) authorized in my Child’s IEP once HCDS reopens for full in-person instruction. I understand that Tele-Therapy means that related services will be delivered using audio/video means for the duration of the session and not in person.

Required

By typing my name in the spaces provided below, this form will be automatically returned Kazzinaro@hawthornecountryday.org, and confirms that I am authorizing Hawthorne Country Day School and my home school district to accept my electronic signature in lieu of an original. *Please type your full name below *

Please Type First and Last Name of Parent or Guardian

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Hawthorne Foundation. Report Abuse

Forms