Deaf Mentor Program Referral ~ Arizona State Schools for the Deaf and the Blind
**Note: Child must be enrolled in either ASDB, PDSD, or Regional Cooperatives Itinrant Services to receive Deaf Mentor Program services. If you have any questions about eligibility please contact:  Bibi Ashley **

The Deaf Mentor Program Administrator will be in contact with you with follow up questions and permissions to begin program support if available.
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Parent/Guardian Name *
Email Address *
Text Phone Number *
Preferred Contact  *
Required
Child's full home address (includes city, state, zip code) *
Name of Child *
Child's Date of Birth *
MM
/
DD
/
YYYY
What language do you prefer for communication? *
Required
Is your deaf/hard of hearing child currently enrolled in school? *
Required
What is the name of your child's Teacher of the Deaf? *
Does the child have any other disabilities that should be considered? *
Some services will be done using Video chat. Do you have in-home access to the internet and a webcam? *
Preferred times to meet with Deaf Mentor (select all that apply): *
Required
During the home visit session, which would you prefer to meet Deaf Mentor?   *
Preschool Teachers of Deaf/HOH or parents:  please write a summary here, if applicable.
Goals of Deaf Mentor Program Services (check all that apply)
Social Engagement ; Meet Deaf/Hard of Hearing Role Models
Social Engagement ; Meet Other Families
Family Learning ; American Sign Language
Family Learning ; Deaf Culture
One-time Works
Occasional Events For Now
Ongoing Learning
Goals of Working with a Deaf Mentor *
Required
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