Information, Authorization and Consent Form
This document indicates your consent to participate in distance-oriented group sessions with the Empower Simcoe EarlyON Program.
This document is designed to inform you about what to expect regarding confidentiality and other details concerning group participation. These group services will be delivered via technology-assisted media, such as telephone (landline and mobile devices), video conferencing, internet, tablet, PC desktop system or other electronic means using appropriate encryption technology.
Limitations of this virtual platform:
Please be aware that there is a risk of misunderstanding group members when communication lacks visual or auditory cues. There may also be a disruption to the service (e.g., phone cuts off, video lags or drops). This can be frustrating and interrupt the normal flow of group interaction.
• I will find a quiet and protected space to attend all group sessions.
• If I cannot attend the video session alone, I will be respectful of the privacy of other participants by wearing headphones.
• I will do my best to remain focused and limit distractions during sessions.
• If there is a loss of connection, I will attempt to call in using the number provided.
• I am familiar with utilizing video conferencing technology and/or agreed upon technology-assisted devices and will ask for assistance if required.
• I understand there are limitations to using virtual platforms and that it is not a complete substitute to the Programs offered by Empower Simcoe EarlyON.
• I understand that a virtual group has potential benefits including easier access to supports and the convenience of meeting from a location of my choosing.
• I understand there are potential risks to this technology which may include interruptions, unauthorized access, and technical difficulties.
• I understand that the EarlyON program facilitator can discontinue the group at any time if it is felt that the videoconferencing connections are not adequate.
• I am aware that group sessions may be recorded to be used for future learning opportunities.
EarlyON Child and Family Centre have a legal obligation to report abuse, neglect and exploitation that is reasonably suspected, disclosed or witnessed.