Therapy Walk Permission Slip
Please review the information and provide your consent for your child to participate in supervised outdoor walks during therapy sessions.
Child's First and Last Name
First Name
Last Name
Child's Date of Birth
-
Month
-
Day
Year
Date
Parent/Guardian's Name
First Name
Last Name
Parent/Guardian's Phone Number
Please enter a valid phone number.
Our therapy office occasionally takes children on supervised walks outdoors as part of their therapy session. These walks may take place on the sidewalks and surrounding areas near our clinic and are used for regulation, movement breaks, social communication practice, or other therapeutic purposes.
Safety & Supervision:
Children will be supervised by their therapist or another staff member at all times.
Walks will only occur in safe, appropriate weather conditions.
If at any time you wish to revoke this permission, you may do so in writing.
I give permission for my child to participate in supervised walks outdoors during their therapy sessions.
Yes, I give permission.
No, I do not give permission.
Signature of Parent/Guardian
Date Signed
-
Month
-
Day
Year
Date
Submit Permission Slip
Submit Permission Slip
Should be Empty: