PA Deaf-Blind Project Virtual Family Learning Conference 2021
Please complete this form as thoroughly as possible to register for this Conference. Once you begin providing information you need to continue until the form is completed. Upon completion click on the submit button to register.
If you have any questions regarding registration please contact Lorraine Byer, lbyer@pattan.net, PaTTAN.

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Email *
Today's Date *
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Parent/Guardian's First and Last Name: *
Parent/Guardian/Child(ren)'s Street Address: *
Parent/Guardian/Child(ren)'s City: *
Parent/Guardian/Child(ren)'s State: *
Parent/Guardian/Child(ren)'s Zip Code: *
Parent/Guardian/Child(ren)'s county of residence: *
Parent/Guardian's Primary Phone *
Deaf-Blind Child's First & Last Name: *
Date of Birth: *
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Age as of June 25th *
Gender *
Where is the child educated? *
What is your Intermediate Unit, if known *
What is the etiology if known *
Please describe the forms of communication your family uses to communicate with your child who is Deaf-Blind.
I understand my child's vision loss to be: *
I understand my child's hearing loss to be: *
Are there siblings? If yes, will any siblings attend the virtual conference? Please list names/ages below: *
I HAVE COMPLETED THIS INFORMATION TO THE BEST OF MY ABILITY AND CONSIDER THE INFORMATION TO BE COMPLETE, TRUE AND CORRECT. YOUR PRINTED NAME BELOW WILL BE REGARDED AS AUTHENTIC AND AGREEMENT ON YOUR PART. *
Signature and Date:
PHOTOGRAPHIC/VIDEO/AUDIO RECORDING PERMISSION AND RELEASE FORM
PA Deaf-Blind Project Family Learning Conference Childcare Program I hereby give my permission to Pennsylvania Training and Technical Assistance Network (PaTTAN), to photograph, videotape, audiotape or any analog/digital means to record actions of said individual named above for advertisement, educational and training purposes. We/I understand and agree there will be no compensation for use of these written or visual materials. I also agree to release and discharge Pennsylvania Training and Technical Assistance Network (PaTTAN),  from all claims and demands of any nature whatsoever arising from or with respect to the use of any interviews, photographs, slides or videotapes. This release shall continue in effect until I give written notice to terminate the use of interviews/pictures of my child, family members or self. Such termination shall not affect the use of any written or visual material obtained before the notice of termination.Your signature below will be regarded as authentic and shall be considered as approval and agreement on your part to the PHOTOGRAPHIC/VIDEO/AUDIO RECORDING PERMISSION AND RELEASE portion for the PA Deaf-Blind Project Family Learning Conference Childcare Program.IF YOU DO NOT AGREE, PLEASE LEAVE THE SIGNATURE SPACE BLANK. Please include the date.
Signature and Date: *
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