Consent for Observation

Leap of Language Inc.

37171 Sycamore Street Apt. 633, Newark, CA 94560

stcin001@gmail.com

205-534-4330

I hereby grant Leap of Language Inc. and their consultants, contractors or employees to observe

in the following settings :

Name of Location:

Daycare

School

Work

Other

For the purpose of:

I understand that during this observation, Leap of Language Inc., their consultants, their contractors, or their employees may speak to providers, clinicians, teachers, employers, etc. about the client and I thereby grant permission for such discussions.

I am the client, parent or legal guardian of the person named below and have the legal authority to provide consent for observation.

First Name of Client

Last Name of Client

Signature of Client or Legal Representative

Today's Date

Relationship to Client