Parental Consent to Use E-mail to Exchange Personally Identifiable Information v 12.3.14

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Family
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E –mail Address
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Child’s Name
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DOB
Enter Local tiny-k Program specific info here

At your request, you have chosen to communicate personally identifiable information concerning your child’s early intervention services by e-mail. E-mail will be sent with encryption which will require a password to open for added protection. Sending personally identifiable information by e-mail has a number of risks that you should be aware of prior to giving your permission. These risks include, but are not limited to, the following:

  • E-mail can be forwarded and stored in electronic and paper format easily and without the prior knowledge of the parent.
  • E-mail senders can misaddress an e-mail and personally identifiable information can be sent to incorrect recipients by mistake.
  • E-mail sent over the internet without encryption is not secure and can be intercepted by unknown third parties.
  • E-mail content can be changed without the knowledge of the sender or receiver.
  • Backup copies of E-mail may still exist even after the sender and receiver have deleted the messages.
  • Employers and online service providers have a right to check e-mail sent through their systems.
  • E-mail can potentially contain viruses and other programs.

Parent(s)/Guardian Acknowledgment and Statement of Consent

I acknowledge being provided a copy of the Child and Family Rights and the Kansas ITS Complaints Process – Kansas Infant Toddler Services. This information has been explained to me and I understand it. As discussed in this information, I have the right to contact the Kansas Department of Health and Environment at 785.296.6135 or 1.800.332.6262 and make an informal complaint, formal written complaint, request mediation and/or an impartial due process hearing should I disagree with the above proposed or refused action(s). For more information, I may also consult the Kansas Infant Toddler Services website at

I have read and understand the items above which describe the inherent risks of using e-mail to communicate personally identifiable information. Nevertheless, I authorize______whose e-mail address is______to communicate with me regarding my child’s participation in the Kansas Infant Toddler Program, including, but not limited to, the child’s Individual Family Service Plan(IFSP), communication regarding service delivery, the child’s progress toward Early Intervention outcomes, and other related matters. By signing below I give permissionfor the local tiny-k program to use encrypted e-mail to communicate with me.

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Parent/Guardian Signature Date
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Parent/Guardian Signature Date

Optional

In addition, I give the following individuals on my child’s treatment team, permission to share personally identifiable information with each other using encrypted e-mail.

  1. ______E-mail______
  2. ______E-mail______
  3. ______E-mail______
  4. ______E-mail______

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Parent/Guardian Signature Date

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Parent/Guardian Signature Date

Note: Parents are to receive a copy of this form.