Parent Forms - Brooklyn Letters

Brooklyn Letters COVID-19 Reopening - Speech Language Therapy

Pursuant to recent orders, Brooklyn Letters is able to resume in-person speech-language therapy. Please complete this form for EACH of your children who will receive in-person services by a Brooklyn Letters Speech Language Pathologist, even if that child has received in-person services at a previous time. COMPLETE A SEPARATE FORM FOR EACH CHILD RECEIVING SPEECH SERVICES. DO NOT INCLUDE MORE THAN ONE CHILD ON EACH FORM.
State your Full Name.*
What is today's date?*
Date Format: MM slash DD slash YYYY
State your Child's Full Name and DOB.*
What is the name of the Brooklyn Letters Speech Language Pathologist who is working with your child?*
Please read the attached Waiver and Release of Liability and verify that you have read it in its entirety and agree to its terms.*
- Yes, I have read the attached Waiver and Release of Liability and agree to its terms in its entirely.
- Yes, I have read the attached Waiver and Release of Liability but DO NOT agree to its terms in its entirety.
- No, I have NOT read the attached Waiver and Release of Liability.
Waiver and Release of Liability Page 1 of 2
Waiver and Release of Liability Page 2 of 2
Please read the attached COVID-19 Reopening Safety Plan and verify that you have read it in its entirety and will abide by its provisions.*
- Yes, I have read the attached COVID-19 Reopening Safety Plan and will abide by its provisions.
- Yes, I have read the attached COVID-19 Reopening Safety Plan but will be unable to abide by one or more of its provisions.
- No, I have NOT read the attached COVID-19 Reopening Safety Plan.
COVID-19 Reopening Safety Plan Page 1 of 4
COVID-19 Reopening Safety Plan Page 3 of 4
COVID-19 Reopening Safety Plan Page 4 of 4
If you WILL NOT be able to abide by one or more of the provisions of the COVID-19 Reopening Safety Plan, please state which such provisions.
I hereby consent to my typed signature below to act as an electronic signature for the Waiver and Release of Liability and COVID-19 Reopening Safety Statement included herein.*
- Yes
- No
Type Full Name as Electronic Signature

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Brooklyn Letters COVID-19 Reopening - Speech Language Therapy

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