EI Parental Consent to Use E-mail to Exchange Personally Identifiable Information

Parental Consent to Use E-mail to Exchange Personally Identifiable Information - Early Intervention
Parent's Name *

First Name Last Name
E-mail Address *
example@example.com
Child's Name *

First Name Middle Name Last Name
Child's Date of Birth *

Month Day Year
Date
At your request, you have chosen to communicate personally identifiable information concerning your child’s early intervention treatment by e-mail without the use of encryption. Sending personally identifiable information by e-mail has a number of risks that you should be aware of prior to giving your permission. These risks include, but are not limited to, the following:
- E-mail can be forwarded and stored in electronic and paper format easily without prior knowledge of the parent.
- E-mail senders can misaddress an e-mail and personally identifiable information can be sent to incorrect recipients by mistake.
- E-mail sent over the Internet without encryption is not secure and can be intercepted by unknown third parties.
- E-mail content can be changed without the knowledge of the sender or receiver.
- Backup copies of e-mail may still exist even after the sender and receiver have deleted the messages.
- Employers and online service providers have a right to check e-mail sent through their systems.
- E-mail can contain harmful viruses and other programs.
Parental Acknowledgement and Agreement
I acknowledge that I have read and understand the items above which describe the inherent risks of using e-mail to communicate personally identifiable information. Nevertheless, I Parent's First Name* Parent's Last Name* authorize Little Angels Center whose email address is ei@littleangelscenter.com to communicate with me at E-mail Address* concerning my child's First Name* Last Name* participation in the Early Intervention Program (EIP), including but not limited to communications regarding service delivery, his/her progress in the EIP and any other related matters. I understand that use of e-mail without encryption presents the risks noted above and may result in an unintended disclosure of such information.
(Optional) In addition, I give permission for members of my child's treatment team to communicate personally identifiable information concerning my child with each other using unencrypted e-mail. Early intervention team members who I give permission to use unencrypted e-mail to communicate with each other about my child include:
(1) Name

First Name Last Name
E-mail
example@example.com
(2) Name

First Name Last Name
E-mail
example@example.com
(3) Name

First Name Last Name
E-mail
example@example.com
(4) Name

First Name Last Name
E-mail
example@example.com
(5) Name

First Name Last Name
E-mail
example@example.com
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

Parental Consent to Use E-mail to Exchange Personally Identifiable Information - Early Intervention