SESLP - Permission to Provide Online Services Form

Permission to Provide Online Services Form - SESLP
Child's Name

First NameLast Name
Child's DOB

MonthDayYear
Date
Name of Parent/Guardian

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Devices you have available:

Desktop computer or laptopiPad/Android tabletiPhone/other smartphone
To best serve your child and family, it may be necessary to utilize our online services. Currently we are using Microsoft Teams as our platform, however, we may expand this to include other platforms such as Zoom. These are free downloadable internet software application to you that allow users to transmit video streaming over the internet, via webcam; and/or to share various kinds of files.

It may be necessary to share this information with other individuals or agencies who are involved with your child. Information to be shared is limited to what is necessary to enable us to continue to work effectively with you and your child. We want you to be fully aware of the risks of using any alternative online options and make an informed decision to consent (or not to) for continued services.
Please confirm your decision by checking one of the boxes below:

Yes, I consent to receiving online servicesNo, I do NOT consent to receiving online services
Parent/Guardian Signature
Today's Date:

MonthDayYear
Date
Should be Empty:

Permission to Provide Online Services Form - SESLP