Consent for Third Party to Attend with Participant Form
Please complete this form if your participant will be having a third party, non-PRCS, staff attend PRCS programming with them. This form gives your consent for PRCS to share information about your participant and allow the individuals listed below to work with your participant during PRCS programs. Examples of third party agencies typically include ABA Therapists, Physical Therapists, Occupational Therapists, Child Find, etc.
Full Name of Participant
*
First Name
Last Name
Program and Site Participant is Attending
*
List Full Names of All Providers Attending with Participant
*
Type of Agency
*
Please Select
ABA
PT
OT
Child Find
LCPS
Nursing
Other
If 'other', please describe
Date Effective
*
-
Month
-
Day
Year
Date
Please provide details about attendance schedule, frequency, etc below
*
Signature
*
Submit
Should be Empty: