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Advocacy Request Form
We appreciate your interest in the Hands & Voices ASTra Education Advocacy Program. While it can be difficult to put into words the many concerns you may have about your child, please fill out this form completely to help us understand your situation and provide us the necessary information to support you in your child’s education planning.

We cannot schedule a time with you to talk or plan to attend any meetings with you until this form is completed.
If you have letters and/or supporting documentation, please attach them to your email submission. We know this is a long form, but it will be helpful to your child’s IEP or 504!
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Email Address: *
Name of Child: *
Child's Date of Birth *
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Child's current age *
Street Address:
City, State and Zip
Phone: *
Name of Family Contact:
Role of Family Contact, and Role (Parent, Guardian, etc.)
Name and contact information of the person who referred you to us:
May we contact the referring person if needed?
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Communication Choice/Methodology - How does your child prefer to communicate? (Check one or any combination & indicate which is the Primary Mode, and whether that is receptive or expressive use.)
What is his/her first language? (English, ASL, Spanish, etc.) *
Does your child have a current Communication Plan on the IEP?
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Describe the communication in your home and at school. Provide a description of communication/language used and any difficulties you see in school:
Describe the communication/language used and any difficulties you notice at home:
Provide a description of communication/language used and any difficulties you see with siblings:
Describe the communication/language used and any difficulties you observe with D/HH friends:
Provide a description of communication/language used and any difficulties you see with hearing friends:
Tell us about the communication/language used and any difficulties you see in other settings:
Hearing level of child, i.e., mild, moderate, severe, profound:  (May attach audiogram to email)
Does the child use amplification?
Hearing Aid
Bone Conduction Aid
Cochlear Implants
All waking hours
Only during school
Other
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Please indicate the child’s primary eligibility on their IEP (For example; Deafness/hearing loss, Autism, developmental delay, learning disability, ADHD, etc.)
Do you have concerns about your child’s ability to learn?
Please indicate your child’s functioning compared to grade level in Reading, Writing, and Math:
School Name, Phone number, and District:
What grade is your child in?
What is your child's placement?
List name, email address, and role of professional service providers most familiar with, & understanding of your child and the situation:
Does CO Hands & Voices have permission to contact the above listed professionals?
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Others on the IEP team:
Advocacy Issues:
Please explain the Advocacy Issues listed above.
Please list relevant information regarding the identification of your child’s hearing loss, as well as early intervention and educational history:
If you made a written request to the school related to your child’s IEP, please describe the request briefly here and attach to email:
Has the Local Education Agency (LEA) - school, or IEP team responded to your request or proposal? (please email copies if you have it in writing)
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Please list other resources/supports currently being used?
 Please include other resources/supports not listed above:
Current status and next scheduled meeting(s) pertaining to this issue:
What do you hope to accomplish?
Please describe how you would like Hands & Voices to help you:
Our advocacy services depend largely on voluntary support. Your membership donation to the CO Hands & Voices Chapter helps provide this type of support to families, and priority is given to members.  Are you a current member of the CO Hands & Voices Chapter? If you'd like to join, go to: https://www.co-hv.org/newsite/about/become-hv/
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