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American Sign Language Assessments- REQUEST
California School for the Deaf

For use with Children who are Deaf or Hard of Hearing
Ages 0 - High School
With IFSP/ IEP
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Child's first name (legal) *
Child's last name (legal) *
Date of request *
MM
/
DD
/
YYYY
Child's classroom or setting
Child's Birth date
MM
/
DD
/
YYYY
Child is enrolled in (Name of the program or School)
Location of the program or School
Name of the Local Education Agency (LEA)
Are you the primary teacher working with this child? *
If you are the primary teacher working with this child, please specify your relationship.
Child's home language(s_: Check all that apply. *
Required
Child's IFSP/ IEP- Primary Disability *
Required
Purpose of ASL Assessment: Check all that apply. *
Required
Request by (First and Last Name) *
Requester's role Check that apply. *
Required
Requester's email address *
Requester's phone number *
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