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Family's Sign up for Deaf Mentor Program:
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* Indicates required question
Email
*
Your email
Family/Caregiver name (last, first)
*
Your answer
Phone number: (use this format 123-456-7890)
*
Your answer
What city/town/county do you reside in?
*
Your answer
Best way to contact you?
*
Email
Phone
Who is your Early Intervention Specialist/Primary Provider that works with your child?
*
Your answer
Information about your deaf/hard of hearing child(ren)? (child's name, age)
*
Your answer
Does he/she have siblings? (child's name, hearing status, and age)
Your answer
Deaf Mentor Home Session - Schedule preference: Pick which day(s) of week work best for your family?
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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Required
Weekdays (Monday through Friday):
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Morning
Afternoon
Evening
Not applicable
Required
Weekends (Saturday/Sunday):
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Morning
Afternoon
Evening
Not applicable
Required
Type of session preference due to Corvid-19
*
Zoom platform
Hybrid method (biweekly alternating Zoom/In person session)
In person sessions
Other (please comment below of this form)
Required
Special Scheduling notes (e.g., I cannot do a session on every other Mondays)
Your answer
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?
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None
1
2
3
4
5
Fluent
Thank you for completing the Sign up for Deaf Mentor Program; any additional information or comments?
Your answer
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