Informed Consent for Virtual Special Education Related Services

Student Name * Required
First Last
Student Date of Birth * Required
MM slash DD slash YYYY
Consent * Required
- I CONSENT for my student to receive virtual related services.
- I DO NOT consent for my student to receive virtual related services. I agree to have the provision of related services placed on hold until in-person visits are permitted. I understand that I will not receive make-up sessions for the period that my student’s related services are on hold.
Electronic Signature * Required
Please write the your name (parent/guardian)
Today's Date * Required
MM slash DD slash YYYY

Reason for Notice

KIPP DC will provide virtual special education related services during school closures as a result of the COVID-19 public health emergency. The virtual related services may include any of the following: audiology, behavior support services, occupational therapy, orientation and mobility, physical therapy, and speech. These services can be delivered using platforms such as, telephone, FaceTime, Google Classroom, Google Duo, and/or Zoom.

Acknowledgement and Statement of Consent

I understand that my student may receive special education related services through virtual visits.

I consent to the delivery of related services by virtual visits over a computer, tablet, smartphone or telephone between KIPP DC related service providers and my student. I understand that the availability of virtual visits will depend on the type of technology, devices or system requirements used.
I understand that the related service providers will have the same licensure/certification and apply the same standard of professional care in a virtual visit as during an in-person visit.
I understand that I will have access to all of my student’s records and information resulting from the sessions conducted through virtual visits the same as I would during in-person visits, and as provided for by law.
As with any internet-based communication, I understand that risks include the possibility of technological problems which may result in poor quality or disconnection from the virtual visit, as well as a security breach without the appropriate protections. To help mitigate security risks, I understand that it is recommended I take steps to protect my personal device and data including using a secure internet network.
I understand that KIPP DC is taking steps to protect my student’s personal identifiable information, and I understand KIPP DC is not responsible for my device security and acknowledge and knowingly accept the risks of accessing service(s) via virtual technology. I understand that KIPP DC recommends using KIPP DC provided technology when possible.
I understand that I am responsible for the cost of technology and device requirements associated with receiving related services through virtual visits (e.g., data/internet plans, personal device).

I understand that the use of virtual visits is only allowable at this time due to the COVID -19 pandemic, and that virtual visits are not a permanent service delivery option. I also understand that I can revoke my consent for virtual services at any time.