Support Professional Parental/Guardian Consent
Name of child the professional will be supporting/observing
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First Name
Last Name
Name of parent/guardian filling out this form
*
First Name
Last Name
Relationship with the child
*
The child is in which program at RayCam?
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Lake Room (daycare)
Mountain Room (daycare)
Out of School Care
Name of professional who will be supporting your child
*
First Name
Last Name
Please state why you would like the service to occur in childcare space.
*
Please confirm that you understand that RayCam Cooperative Association and its employees do not have any responsibility towards the content of the visit.
*
I confirm
Please confirm that you understand that no notes or messages can be left with RayCam Cooperative Association's staff to be passed on to you. The professional must directly communicate with you.
*
I confirm
Please confirm that you understand that it will your responsibility to inform RayCam Cooperative Association staff in writing if you choose to withdraw consent for the visits.
*
I confirm
Please confirm that you will inform childcare staff the dates and times you expect the visit to occur.
*
I confirm
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: