Purchase Line School District

16559 Route 286 HWY E

Commodore, PA 15729

You have my permission for my child ___________________ to participate in small group online speech therapy sessions. 

______________________________        _________________________________

Child’s name printed                                  Parent’s name printed

______________________________        _________________________________

Date                                                            Parent’s signature 

I choose to have the Speech & Language Clinician to use the following email address for scheduling ZOOM meetings for speech therapy.  [This can be your personal email or your child’s email on Chrome book or both] 

Parent email address:  _________________________________________________

Student email address:  ________________________________________________

__________________________                            _____________________________

Date                                                                        Parent’s signature

Return this form to Jennifer Rising – Purchase Line Elementary School