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COVID-19 Responsibilities: Parent/Guardian Acknowledgment

As a result of the current pandemic, EE Support Services have implemented protocols and procedures
in the best interest of the health and safety of our clients and staff, their families, and others. The
adherence to these protocols is the responsibility of all Exceptional Expectations’ clients.

Parent or Guardian Name*

Parent or Guardian Email*

By signing this document I hereby certify that I am the parent and/or legal guardian of:*

I acknowledge that it is my responsibility to notify Exceptional Expectations of any health or medical concerns pertaining to household members.*

I acknowledge that if my child displays any of these symptoms, it is the parent/guardian's responsibility to contact Exceptional Expectations.*

I acknowledge that it is my responsibility to report to Exceptional Expectations if my child or anyone who they have come into contact with has been diagnosed with or has symptoms of COVID-19.*

I acknowledge that sanitation procedures such as use of hand sanitizer, hand washing, and the use of sanitizing wipes for supplies and surfaces are highly suggested for in-home visits.*

I acknowledge that I will notify Exceptional Expectations and my in-home service provider of any allergies or sensitivities to any of the above-listed sanitation products, as well as any allergies/sensitivities in relation to personal protective equipment (i.e. latex gloves, face masks, etc.) that my child may come into contact with.*

I acknowledge that Service Providers of Exceptional Expectations are not authorized to administer any medications while providing services without the express written approval of a Director of Exceptional Expectations, L.LC. To the extent that the administration of medication is necessary, it is the responsibility of the Client to provide the Service Provider with adequate instruction.*

If you or anyone in your household has come into more than passing contact with someone (e.g., coworker, friend, extended family, etc.) who has tested positive for Coronavirus please contact the Agency Director Alexxa Roberts or email enrollment@exceptionalexpectations.com immediately to determine next steps.*

Signature of Parent or Guardian*

Signature Date 1*

Year/Month/Day