2021 Social Media, Encrypted Email & Covid Waiver

Video/Photography/Social Media Consent; Encrypted Email Policy & COVID-19 Liability Release Waiver
Please enter the Access Code provided to fill out the form.*
Child's Name*

First NameLast Name
Child's Date of Birth*

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Parent/Guardian Name*

First NameLast Name
Email*
example@example.com
Relationship to child*
VIDEO, PHOTOGRAPHY & SOCIAL MEDIA CONSENT
At Therapy West, Inc., therapists videotape or photograph children who receive therapy services to help monitor and document a child’s areas of concern, as well as measure their progress. Videotapes and photos are used and reviewed by Therapy West, Inc. staff and occasionally may be used in research projects focusing on outcome measures.

Therapists are frequently asked to participate in research and teach at professional courses, seminars or workshops nationally and internationally, as well as to write articles or chapters in technical books. We often include videotapes, slides or photos during our presentations. If photos or videos are used for any of the above mentioned purposes, they will not have identifiable information. Parents are always welcome to view their child’s videotape at Therapy West, Inc.
I give consent for my child to be videotaped and/or photographed. I understand that my child's name and any identifying information will not be used in association with these images.*

YesNo
Therapy West, Inc maintains a brochure, website, Facebook page and Instagram page. Please mark your consent for staff and therapists at Therapy West, Inc to take photographs and videos of my child for the purpose of posting on these sites. With this consent, I hereby release and discharge Therapy West, Inc from any and all claims arising out of use of the photos and videos. This consent can be changed and revoked by parent at any time.
I provide consent for Therapy West, Inc to use photographs of my child on Therapy West, Inc.'s brochures:*
I provide consent for Therapy West, Inc to use photographs and videos of my child on Therapy West, Inc's website:*
I provide consent for Therapy West, Inc to use photographs and videos of my child on Therapy West, Inc's Facebook and Instagram pages. I understand that these posts may be accompanied with my child's first name. :*
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ENCRYPTED EMAIL POLICY
Therapy West, Inc. uses an encryption service when sending emails with PHI (personal health information) in order to protect me/my child’s PHI in compliance with recommended HIPAA regulations.

Please read the following statements, choose appropriate box, and sign below.
I understand that Therapy West, Inc. uses an encryption service when sending emails with PHI (personal health information) in order to protect me/my child’s PHI in compliance with recommended HIPAA regulations.

I am choosing to receive encrypted email from Therapy West. I understand that I will need to set up and enter a self-created password each time I want to access an encrypted email.I am choosing to decline receiving encrypted email and accept the risks associated with receiving PHI through unencrypted email
Signature of Parent/Caregiver completing form:*

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Today's Date:*

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If at any time you would like to start receiving encrypted emails or decline encrypted emails, please contact Therapy West, Inc. at (310) 337-7115 and let us know. You will need to fill out and sign an updated form. Thank you.

COVID-19 LIABILITY RELEASE WAIVER
The World Health Organization has declared the novel Coronavirus (COVID-19) a worldwide pandemic. Due to its capacity to transmit from person-to-person through respiratory droplets, the government has set recommendations, guidelines, and some prohibitions which Therapy West, Inc (the "Organization") adheres to comply.
In consideration of my participation in the foregoing, the undersigned acknowledge and agree to the following:*

I am aware of the risk of myself and my child participating in activities that may cause injury or illness such as, but not limited to Influenza, MRSA, or COVID-19 that may lead to paralysis or death.I agree to not participate in therapy services if any member(s) in our household experiences symptoms that of fever, fatigue, difficulty in breathing, or dry cough or exhibiting any other symptoms relating to COVID-19 or any communicable disease within the last 14 days.I agree to not participate in therapy services if any members(s) in our household traveled by sea or by air within the past 14 days.I agree to notify the Organization if any member(s) in our household are diagnosed or test positive for COVID-19 virus within 14 days of an appointment.
By signing below I acknowledge that I have read the foregoing Liability Release Waiver and understand its contents; that I am at least eighteen (18) years old, am the legal guardian of the child and fully competent to give my consent; that I have been sufficiently informed of the risks involved and give my voluntary consent in signing it as my own free act and deed; that I give my voluntary consent in signing this Liability Release Waiver as my own free act and deed with full intention to be bound by the same, and free from any inducement or representation.

This waiver will remain effective until laws and mandates relevant to COVID-19 are lifted.
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Video/Photography/Social Media Consent; Encrypted Email Policy & COVID-19 Liability Release Waiver

VIDEO, PHOTOGRAPHY & SOCIAL MEDIA CONSENT

ENCRYPTED EMAIL POLICY

COVID-19 LIABILITY RELEASE WAIVER