| Application
for Enrollment |
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* These answers are REQUIRED
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| Family
Information |
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Child's
Information |
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| *Father's Name
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*Child's Name |
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First Name |
Middle Initial |
Family Name |
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First Name |
Middle Initial |
Family Name |
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| *Mother's Name |
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Sex:
Male
Female |
First Name |
Middle Initial |
Family Name |
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*Date
of Birth:
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| Marital
Status:
Married
Living Together
Separated
Divorced
Single |
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mm/dd/yyyy |
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Child's
Audiological Information |
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Degree of Hearing
Loss:
Slight
Mild
Moderate
Moderately Severe
Severe
Profound |
| Father's
Occupation:
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full time?
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| Mother's
Occupation:
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Cause
if known:
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full time?
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When
did you suspect the hearing loss?
months |
| Contact
Information |
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When
was the loss confirmed?
months |
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Does
your child have a listening device?
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*Address:
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If
so, when received?
years
months |
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Number,
Street |
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Type:
Hearing Aids
One
Two |
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Body-worn
Behind the ear (BTE) |
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City,
State, Postal Code |
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Auditory Trainer
Bone Conduction Aid |
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Cochlear Implant (manufacturer:
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Country |
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Has your child had any recent hearing tests or evaluations? If so, please
send us a copy. |
| Telephone
No:
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| Fax
No.:
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List
other handicaps:
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| *Email Address:
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Medical
treatment, if any:
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| *Confirm Email Address:
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| Do
you have a VCR (video cassette player)?
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Agencies,
clinics or doctors that have seen your child: |
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| Sibling
Information |
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| Other
Children's Full Name, Birthdate and Sex: |
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Masc.
Fem. |
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First & Last ,
Birthdate: mm/dd/yy |
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Masc.
Fem. |
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Child
Care Arrangements |
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Fist & Last,
Birthdate: mm/dd/yy |
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Masc.
Fem. |
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child care center
hrs/day
times/week |
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First & Last,
Birthdate: mm/dd/yy |
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baby-sitter
hrs/day
times/week |
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| Motor
Skills (check all that apply to your child) |
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Holds/reaches for objects
Holds head up
Sits by self
Crawls
Walks Independently |
| Eating |
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Uses bottle/nurses
Feeds self |
| Education |
| Describe
educational services/therapy your child is receiving.
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| Additional
Information |
| Are
there other deaf family members?
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| List
languages spoken in your home
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| Is
your child adopted?
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| Was
your baby premature?
If yes, born at what month?
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| Was
your baby healthy at birth?
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| What
illnesses has your child had since birth? When?
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| What
sounds, if any, does your child understand?
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| What
words, if any, does your child use?
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| Does
your child put any words together in phrases or short sentences?
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| Are
you using formal sign language?
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| Who
referred you to John Tracy Clinic?
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Note:
We are aware that name usage differs in some countries - and also with
individuals.
When we write letters to one or both parents, we want to be both correct
and respectful.
What salutation should we use?
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Comments
or Questions (space to include anything you
may want to add to this application)
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| Important:
We offer two ways for you to receive your lessons. Please
select one of the following options:
*
I would like to download my lessons
I would like to receive my lessons through the mail. |
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Submit Code:
eivasv
*Please enter the Submit Code:
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