Family's Sign up for Deaf Mentor Program:
Email *
Family/Caregiver name (last, first) *
Phone number: (use this format 123-456-7890) *
What city/town/county do you reside in? *
Best way to contact you? *
Who is your Early Intervention Specialist/Primary Provider that works with your child? *
Information about your deaf/hard of hearing child(ren)? (child's name, age) *
Does he/she have siblings? (child's name, hearing status, and age)
Deaf Mentor Home Session - Schedule preference: Pick which day(s) of week work best for your family? *
Required
Weekdays (Monday through Friday): *
Required
Weekends (Saturday/Sunday): *
Required
Type of session preference due to Corvid-19 *
Required
Special Scheduling notes (e.g., I cannot do a session on every other Mondays)
General Questionnaires: On a scale from 1 to 5, with 1 being low and 5 high, where would you rate yourself/family in your ability to use ASL? *
None
Fluent
Thank you for completing the Sign up for Deaf Mentor Program; any additional information or comments?
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