NH Deaf/Hard of Hearing Role Model Program Referral
Today's Date:
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Month
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Day
Year
Date
Contact information of the person completing the referral:
Child's Name:
First Name
Last Name
Child's Date of Birth:
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Month
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Day
Year
Date
Parent/Guardian Contact Information
Family’s primary language:
English
Other
If other:
Child's hearing history
Is the family receiving early intervention services?
Yes
No
If yes, what is the name of the early intervention program?
The family would like to meet a Deaf/Hard of Hearing Role Model whose preferred communication mode is:
American Sign Language (ASL)
Bilingual/Bimodal approach of ASL and Spoken Language
Cued Speech
Listening and Spoken Language (LSL)
Multiple communication apporaches
No preference
Prefer the visit to be:
In-person
Virtual
Submit
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