SSP Profile Application
Please complete this form for the October 28-29, 2017 Support Service Provider (SSP) Training.

Description:
The Office for the Deaf and Hard of Hearing, in the Wisconsin Department of Health Services Division of Public Health, will be hosting a Support Service Provider (SSP) in October 2017. Individuals interested in providing SSP services for compensation through the Service Fund program will need to complete this training.

Full Name *
Your answer
Phone (text/voice/VP) *
Your answer
Alternative Phone/Contact Number
Your answer
Address *
Your answer
Email Address *
Your answer
What is the best way to contact you?
What is your first language? *
Required
If you are fluent in other languages, please list them below.
Your answer
Preference of communication *
Required
What credentials do you hold? *
Required
What experience do you have with low vision/Blindness? *
Required
Please list all certifications you currently have, if they were not listed in the 2 questions above.
Your answer
How many years have you worked with people who have low vision or who are Blind? *
How many years have you worked with people who are Deaf and use ASL? *
How many years have you worked with people who are hard of hearing? *
How many years have you worked with people who are DeafBlind? *
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