GROWING EXTRAORDINARY: Read and Imagine with Dr. Jasmine Click here to download the flyer for this event. Parent's (Guardian) First & Last Name * First Name Last Name Phone Number * (###) ### #### Email Address * 1st Child's With Hearing Loss First & Last Name (aged 0-3) * First Name Last Name 1st Child's Date of Birth * 2nd Child With Hearing Loss First Name Last Name 2nd Child's Date of Birth Please tell us how many adults and children will be attending. Number of Adults Number of Children 0-3 years old Number of Children 4+ years old What County do you live in? * Primary Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Tell us about your child's hearing loss * Do they use hearing technology? * Is your child currently receiving any early intervention services or have they received services in the past? * Yes No If yes, where are they currently / did they receive services? * What language(s) are used in the home? * Do you need an interpreter? * Yes No If yes, what language? ASL Spanish Other What session time are you planning to attend? * Session A – 9:30 AM to 11:15 AM Session B – 11:15 AM to 1:00 PM Do you have any questions or comments? Thank you!
