Question Title * 1. I am a ___________________ of a child between the age of 0-21 who is Deaf/Hard of Hearing and/or Blind/Visually Impaired. Parent, Family Member, Guardian, Friend Professional Other Other (please specify) Question Title * 2. I am attending to benefit a child who is _________________ birth– age 12 and Blind/Visually Impaired age 12 –21 and Blind/Visually Impaired birth– age 12 and Deaf/ Hard of Hearing age 12 –21 and Deaf/ Hard of Hearing Question Title * 3. I would like to request the following accommodations: Large Print Braille ASL Interpreter Foreign Language Interpreter (please specify in comment box) Other (please specify in comment box) Comment Field Question Title * 4. My child attends ___________________________. Florida School for the Deaf and the Blind a school in Palm Beach County Other Other (please specify) Question Title * 5. The diagnosis of the child I am attending to benefit is__________________. (ex. ocular albinism, bilateral moderate hearing loss) Question Title * 6. Please rank the following statements in order of importance, with 1 being most important and 4 being least. 1 2 3 4 I am excited to learn how to support my child in the area of academics. 1 2 3 4 I am excited to learn how to support my child in the area of social/emotional. 1 2 3 4 I am eager to meet other families of children who are Deaf/HH and/or Blind/VI. 1 2 3 4 I am eager to meet professionals working with children who are Deaf/HH and/or Blind/VI. Question Title * 7. My name is_____________________ Question Title * 8. Please contact me via______________ email (enter this information in the comments box) phone (enter this information in the comments box) video phone(enter this information in the comments box) Comments Box Question Title * 9. Is there any additional information you feel is important for us to know about your family or child? Question Title * 10. Is there a specific area that you hope to learn about? Next
