CONSENT FOR ONLINE SPECIAL EDUCATION AND RELATED SERVICES
HAWTHORNE COUNTRY DAY SCHOOL
CONSENT FOR THE USE OF TELE-THERAPY DURING DECLARED STATE OF EMERGENCY FOR COVID-19

The consent form for the use of Tele-Therapy must be completed by the parent/guardian and submitted so Tele- therapy sessions can begin.
Email address *
Child's Name: *
Child's First and Last Name
Your answer
Students DOB: *
MM
/
DD
/
YYYY
Phone Number # : *
Your answer
Home School District *
Please Choose one: *
Please check all that apply *
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. *
Required
By typing my child's name below, this form will be automatically returned to Kazzinaro@hawthornecountryday.org and confirms that I am authorizing the District to accept my electronic signature in lieu of original. *
Please Type First and Last Name of Parent or Guardian
Your answer
Please Choose 1 *
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 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
Your answer
A copy of your responses will be emailed to the address you provided.
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