School Therapy Program Consent Form
Date of Birth:
At Home Program
Autism Diagnostic Team (Coordinator, Interior Children's Assessment Network, Psychologist, SLP, OT, Pediatrician)
BC Children's Hospital
Public Health (IHA) (Public Health Nurse, Dietician, Speech Therapist, Audiologist)
Child and Youth Mental Health
SD #73 (Kamloops Thompson)
SD #58 (Merritt)
SD #74 (Gold Trail)
Infant Development Program
Sunny Hill Health Centre for Children
Other Family Members:
Ministry for Children and Family Development
I hereby authorize the staff of CTFRC to help my child with toileting needs as required.
I hereby give my consent to allow audio/visual records to be taken of my child for the following reasons:
To be used for the child's treatment. This information may be shared with the child's team.
To be used for teaching and workshops. It is understood that the child will not be identified by name. I waive all rights to payment or royalties in connection with any presentation of these photographs/videos now and in the future
To be used by the Children's Therapy and Family Resource Centre now and in the future for public community relations, eg. brochures, display boards, print material and fund raising.
legal guardian) - Electronic Signature Assumed
Relationship to Child:
This consent is valid until your child graduates from school or until he/she is discharged from the School Therapy Program. Please contact the centre if you wish to make any changes to this consent at any time.