Parent Application

(if not English)
Which medical professional or affiliated hostpial? Or other referral source?

I hereby confirm that I am the mother/father/guardian of the child for whom I am submitting the following application. I hereby acknowledge my child’s experience and involvement within the non-profit organization, A Free Bird, and consent to the following:

  1. Visitation from a range of professionals within the field of art of my child’s interest for both a duration of time as well as frequency throughout the week agreed upon by both parents/guardians and medical professionals.
  2. The selected professional along with a staff member will be visiting my child as his/her place of current residence, be it within the home or hospital or other facility.
  3. During the time my child is interacting with this professional, both will be supervised and I will be present at all times.
  4. My child’s safety and well-being will be a top priority during all sessions spent with the selected professional.
  5. I am sharing privileged and confidential information, including patient information protected by federal and state privacy laws, with A Free Bird for the purpose of matching my child up with the appropriate A Free Bird arts tutor and/or volunteer. A Free Bird will not share this information with any third parties.

By submitting this application, I agree to the terms above.