of the Finger Lakes
|Consent to Release Information between CAFL and Parents|
*Child's First Name:
*Child's Last Name:
*Date of Birth (MM/DD/YYYY):
*Parent's E-mail: (If not giving consent, please type in "no email address")
Additional Parent's Name:
Additional Parent's E-mail:
Additional Parent's Cell:
*MUST check ONE
I give consent:
I DO NOT give consent:
(If checking this box, please type in "no email address" above)
for Clinical Associates of the Finger Lakes (CAFL) staff to communicate personally identifiable educational information concerning my child with me using unecrypted e-mail, text message, or non-electronic methods.
|Electronic Signature Log Consent|
I give consent to the following additional individuals to sign the electronic signature log after the delivery of a therapy session.
Please note: If your child will be receiving services in a preschool or daycare setting, please include teacher name and email address.
Cell Number or E-mail:
Cell Number or E-mail:
|Consent to Release Information between CAFL and Others Related to Authorized Services|
*MUST check ONE
I give consent to all team members (if checking this box, there is no need to complete the checkboxes/information below):
I give consent ONLY to those checked below:
I do NOT give consent:
to communicate personally identifiable information concerning my child with each other using unencrypted e-mail, text message, or non-electronic methods. Please check the boxes that apply if only giving consent to certain individuals.
Team members and other professionals:
Sending personally identifiable information by e-mail or text has a number of risks of which you should be aware prior to giving your permission. These risks include, but are not limited to, the following: E-mails and texts can be forwarded and stored in electronic and paper format easily without prior knowledge of the parent; can be changed without the knowledge of the sender or receiver; can contain harmful viruses and other programs. In addition, e-mail sent over the internet without encryption is not secure and can be intercepted by unknown third parties; back-up copies of e-mail may still exist even after the sender and receiver have deleted the messages; and employers and online service providers have a right to check e-mail sent through their systems.
Parental Acknowledgement and Agreement: I acknowledge that I have read and understand the items above, which describe the inherent risks of using e-mail and text to communicate personally identifiable information. By checking the box indicating either “I give consent”/”I do not give consent,” I either allow or deny permission for the members of my child’s team to share and exchange information including communicating personally identifiable information concerning my child using both electronic (unencrypted e-mail/text message) and non-electronic means with the individuals/ agencies indicated above. I understand that this consent is subject to cancellation at any time. This consent shall not be used for the release of confidential, HIV-related information without specified, additional consent.
|Acknowledgement of Notification/Signature|
* I have received notice of my rights under the Federal Family Educational Rights and Privacy Act (FERPA) from Clinical Associates of the Finger Lakes (CAFL).
* I understand that a parent/legal guardian/caregiver who is 18 years of age or older must be present for the entire session, may not leave the premises during the session and is responsible for attending to the child’s needs comforting, toileting, diapering, medicating, feeding, etc.
* By checking this box, I consent to the information contained in this form. This represents my legal electronic signature.