Social Outings Permission Form-PlayRx

Social Outings Permission Form

PlayRx is providing the opportunity for social outings and interactions with other children during scheduled therapy appointments. We will be identifying appropriate peers as well as appropriate social situations to work on communication, play, and social skills. These outings are intended to work on identified skills in a real-life, but controlled, environment. Attendance and consent are entirely at-will. Due to the nature of these therapeutic outings, it is likely that certain aspects of your child's Personal Health Information (PHI) may be revealed to outsiders. Team members will make every effort to keep the focus of the outings on increasing the social skills of the children involved. At no point will unrelated details of your child be discussed without explicit, written permission. Transportation will be at the discretion of parents, and PlayRx is not liable for any accidents that may occur while transporting.

Please check the following boxes to signify your understanding and agreement of each point:

Given this information, I consent to have my child participate in scheduled social outings with PlayRx.

I have been informed and understand all potential risks and benefits of these outings, however, I may withdraw my consent at any time. However, I understand I cannot revoke consent for actions that have already taken place.

I will provide transportation to and from social outings for my child.

Child's First and Last Name

Parent's First and Last Name

Parent Signature Date

Your Signature