Purchase Line School District 

16559 Route 286 Hwy E 

Commodore, PA 15729 

Consent for TeleIntervention Services 

1. I understand that my child’s therapist/teacher has invited my child to engage in teleIntervention services. 
2. My child’s therapist/teacher explained to me how the video conferencing technology that will be used will work during teleIntervention sessions. 
3. I understand that teleIntervention sessions have potential benefits including easier access to care and the convenience of meeting from a location of my choosing during the COVID-19 (Coronavirus) Pandemic.  
4. I understand there are potential risks to technology, including interruptions, unauthorized access and technical difficulties.  I understand that my child’s therapist/teacher or I can discontinue the teleIntervention session if it is felt that the video conferencing connections are not adequate for the situation. 
5. I have had a direct conversation with the therapist/teacher, during which I had the opportunity to ask questions in regard to this procedure.  My questions have been answered and the risks, benefits, and any practical alternatives have been discussed with me in a language in which I understand.   

Consent to use TeleIntervention by Zoom 

Zoom is the technology service we will use to conduct teleIntervention video conferencing sessions.  It is simple to use and there are no passwords required to log in   By signing this document, I acknowledge: 

1. I do not assume that the therapist/teacher has access to any or all of the technical information in the Zoom Service--or that such information is current, accurate, or up-to-date.  I will not rely on my therapist/teacher to have any of this information in the Zoom Service.  
2. To maintain confidentiality of my child and any other children receiving services, I will not share my teleIntervention appointment link with anyone unauthorized to attend the appointment and will not disclose the identity of other children observed during teleIntervention. 

By signing this form, I certify: 

• I have read or had this form read and/or had this form explained to me. 
• I fully understand its contents including the potential risks and benefits of teleIntervention services.  
• I have been given ample opportunity to ask questions and that many questions have been answered to my satisfaction. 
• I am aware of the Children's Online Privacy Protection Act of 1998 (15 U.S.C. 6501-6508) and consent to allowing my child use the telecommunication and/or email communications concerning the above. 

________________________________________                                 ____________________              parent/guardian signature date 

______________________________________(student’s name)