Family Intake Form for CSC Services
Please fill out this form to sign up for:
- Read to Your Deaf Keiki (formerly SRP; for families with deaf/hoh child ages 0-8) - A deaf tutor teaches adults how to read to deaf children in ASL
- Deaf Mentor Pilot Project (for families with deaf/hoh/db child ages 0-5) A deaf adult visits with families to share their experience, challenges and successes as a deaf person.
- CSC Family Network A listserv that allows CSC to contact families when new programs arrive.
- To share your thoughts on supports or services that are needed

The CSC is thrilled to be collaborating with the Newborn Hearing Screening Project (NHSP), MCH-LEND, and Department of Health to better serve Hawaii's families with deaf, hard of hearing, and deaf-blind children ages 0-5. If you have a question about any of these programs, please feel free to contact CSC"s Ohana Liaison Kim Duncan at kimduncan.csc@gmail.com. Mahalo!

Family Last Name
Your answer
Deaf/Hard of Hearing Child's Name *
Your answer
Deaf/Hard of Hearing Child's Date of Birth *
MM
/
DD
/
YYYY
Does your child also have vision loss? *
Home Address
Your answer
Parent/Guardian Name #1
Your answer
Relationship to Child
Your answer
Email
Your answer
Phone Number
Your answer
Does this number accept text messages?
Parent/Guardian Name #2
Your answer
Relationship to child
Your answer
Email
Your answer
Phone Number
Your answer
Does this number accept text messages?
Names and ages of other children in the home
Your answer
Please sign up for services (you may choose more than one.)
Is there a support or service that you are looking for? Please describe it here.
Your answer
Confidentiality Waiver - I hereby authorize the release of my contact information and condition of my child to other parents or appropriate professional staff to support other parents of children who are deaf, hard of hearing, or deaf-blind. If you agree, type your full name.
Your answer
What is the name of your Early Intervention specialist?
Your answer
What is his/her contact information?
Your answer
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This form was created inside of CSC.