Deaf Mentor Family Intake Form
Aloha! The Deaf Mentor Pilot Project (DMPP) has been established to provide ASL instructional services, consultation, mentorship, and advocacy as appropriate and based on the individual needs of children birth to 3 years old and families who have been authorized to receive these services by the DOH-EIS. Criteria has been determined by DOH-EIS. Please fill out this form so we can pair you with a deaf mentor or to receive additional information. Please feel free to contact Roz Kia at roz@csc-hawaii.org or (808) 284-3551 if you have any questions. Mahalo!
Family Last Name
Your answer
Home Address
Your answer
Parent/Guardian Name (Primary contact)
Your answer
Email
Your answer
Phone Number
Your answer
Deaf/Hard of Hearing Child's Name and Age
Your answer
Names and ages of other children in the home
Your answer
What is the name of your Early Intervention specialist?
Your answer
What is his/her contact information?
Your answer
Please select one.
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