NH Deaf/Hard of Hearing Role Model Program Referral
Contact information of the person completing the referral:
Child's Date of Birth:
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:
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
Listening and Spoken Language (LSL)
Multiple communication apporaches
Is the family receiving early intervention services?
If yes, what is the name of the early intervention program?
Is the family working with a Teacher of the Deaf (TOD)?
If yes, who?
Prefer the visit to be:
Should be Empty: