Gallaudet University Regional Center, No
rthern Essex Community College | 100 Elliott St., Haverhill, MA 01830
978-556-3701 (tel) | 978-241-7057 (vp) | 978-556-3703 (fax) | fslp@necc.mass.edu | www.necc.mass.edu/gallaudet
Yes No
Preferred phone number:
Cell phone number:
Can you accept text messages?
Language spoken in the home:
Preferred language of phone calls:
Any pets/allergens in the home:
Describe parking conditions at home:
Do you have access to watch a DVD?
Yes No
Deaf
Hard of Hearing
Parent/Guardian Names:
Street Address:
City/State/Zip:
Email address:
Child's Name:
Child is: (please check)
Child’s Date of Birth:
Gender: Male
Female
Does the child have any additional special needs?
Date of identification of hearing loss :
Where:
Who referred you to FSLP?
Name of Early Intervention (EI) agency:
EI contact person:
Email address:
Phone number:
Address:
City/State/Zip:
Additional notes:
Any other agencies/programs working with your
family and/or your child?
Approximately how many people plan to join the family
for the Family Sign Language Program classes?
Please list the ages of any siblings that may participate:
Please list options of days of the week/times of the day
that you would prefer for classes. Classes typically last 11/2-2 hrs
NOTE: Although classes are offered during daytime hours,
many of our tutors have more availability during evening
hours and on weekends.
1)
2)
3)
Attention EI Providers: Please attach a release form from the parents/guardians.
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