NH Deaf/Hard of Hearing Role Model Program Referral
Today's Date:
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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
1. Preferred Date/Time of Visit:
2. Preferred Date/Time of Visit:
3. Preferred Date/Time of Visit:
Family’s primary language:
English
Other
If other:
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
Is the family receiving early intervention services?
Yes
No
If yes, what is the name of the early intervention program?
Is the family working with a Teacher of the Deaf (TOD)?
Yes
No
If yes, who?
Prefer the visit to be:
In-person
Virtual
Submit
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