JTC's International Session for Listening Spoken Language (LSL) International (Summer) English Session 2023 Parents with Children Ages 2-6 years Please be sure to fill all the boxes on the form. 1Parent Information2Child Information3Session4Mailing Address5Media Release6Demographics7Upload Parent InformationHiddenSession Key* Email* Enter Email Confirm Email Parent Name* First Last I am the* Father Mother Occupation* 2nd Parent Information Add 2nd Parent Information 2nd Parent Name* First Last Significant Other is the* Father Mother Occupation* Child InformationChild's Name* First Last Child's Birth Date* MM slash DD slash YYYY Gender* Male Female Primary Language in Home* Secondary Language in Home Age of DiagnosisYear*Please choose...012345Month*Please choose...01234567891011History of childhood hearing loss in the family* Yes No Amount of Hearing Loss (Right Ear)*Please choose...NoneSlight 15-24 dBMild 25-39 dBModerate 40-70 dBSevere 71-90 dBProfound 91+ dBAmount of Hearing Loss (Left Ear)*Please choose...NoneSlight 15-24 dBMild 25-39 dBModerate 40-70 dBSevere 71-90 dBProfound 91+ dBCause, if known* Devices your child is using now* This field is required.ABI ABI (Auditory Brainstem Implant) Model / Type* Side*RightLeftBothCochlear Cochlear Implant Model / Type* Side*RightLeftBothHearing Hearing Aid Model / Type* Side*RightLeftBothBAHA Bone-Anchored Hearing Aid (BAHA) Model / Type* Side*RightLeftBothRemote Microphone Remote Microphone Age child started using it consistentlyYear*Please choose...012345Month*Please choose...01234567891011Child InteractionsFamily speaking in their home language is required. Check other communication approaches if used regularly.*Family Communication Spoken Language Sign Language of Country (ASL, BSL, ISL, LSF, LSM, etc.) Total Communication Cued Speech Visual Supports Listening* Notices Sounds Imitates Sounds Enjoys Noisy Toys Reacts to Voice Responds to Spoken Language Receptive Language* Responds to gestures Follows directions Enjoys stories and books Comprehends many words Understands grammar HiddenLanguage* Understand Gestures Looks at Pictures and Books Says Single Words/Phrases Uses Short Sentences Answers Simple Questions Expressive Language* Points to pictures/words Speaks in words/phrases Uses short sentences Answers varied questions Enjoys conversations Speech Imitates some words or phrases Produces most speech sounds in words Talks in spontaneous speech Uses longer words but may be unclear Speech skills seem to match hearing age HiddenInternational SessionHiddenSession Preference*Choose onePreschool International Session (07/12/2020 - 07/24/2020)Child Health HistoryBirthing Conditions (Check all apply)* Neonatal intensive care Exchange transfusion Resuscitation Oxygen Incubator Respiratory distress Jaundice Infections/Viruses None Other Other, please specify* Specific illnesses and the age of occurrence*Allergies*List regular medications and dosages* Age Sat UpYear*Please choose...012345Month*Please choose...01234567891011 Age TalkedYear*Please choose...012345Month*Please choose...01234567891011 Age WalkedYear*Please choose...012345Month*Please choose...01234567891011Development(Check all that apply)Plays* With other children With adults Alone Activity Level* High Average Under Attention Span* Very Short Average Very long Development* Behind Average Advanced HiddenToileting* Not trained Tells adults toileting needs Independent Wears diapers Wears training pants Toileting* wears diapers indicates discomfort uses training pants tells adult toileting needs independent Dressing (puts on and takes off)* Shirt Pants Shoes Listening Device Describe your child's current developmentMotor*Eating*Sleeping*Any concerns about child's development*Any concerns about child's behavior*Favorite toys or activities*Describe situations when child is easily frustrated*Examples of spoken requests child responds to*Examples of spontaneous spoken words or sentences*Services/support (Education and therapy reports can be sent after acceptance)Services/support put Y if received this year or N if notBehavior* Yes No Education* Yes No Physical/Occupational Therapy* Yes No Speech/Language* Yes No Vision* Yes No Preschool* Yes No Daycare* Yes No Early Intervention* Yes No HiddenOther services my child received this year: Other services received this year: HiddenPreschool* HiddenDaycare* HiddenEarly Intervention* HiddenSpecial education* HiddenAutism support* HiddenSpeech* HiddenOccupational Therapy* HiddenOther Services* Caregivers, in addition to parent(s)* Grandparents Relatives Friends Daycare Sitter No one besides immediate family Adult Participation*NameRelation to child HiddenAdult Participation Name Relation to child Hearing Loss Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. HiddenSibling Participation* Yes No HiddenSibling Name Date of Birth Hearing Loss Participation Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. 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HiddenPicture of me and my minor (children)* Yes No HiddenPortion of written comments (with Initials or first name)* Yes No DemographicsHow would you identify yourself*Please choose...AfricanAsianBlack / African AmericanCaucasian (European, North / South American)Hispanic / LatinixMiddle EasternNative AmericanPacific IslanderPrefer not to sayOtherOther, please specify* What is your formal education*Please choose...No formal schooling1-8 years9-11 yearsHigh school graduates13-15 years (some college)16 years (college / university graduate school)16+ years (graduate school)What is your employment status*Please choose...StudentPart-timeFull-timeUnemployedHomemakerNumber of adults in household* Number of children under 18 yrs old in household* Do you have health insurance or receive medical financial help* Yes No How did you hear about us?* Referral from professional Internet Search Social Media Suggestion from Parent/Friend Other Other, please specify* Upload Files (e.g. report, evaluation, and picture of child)For this application to be reviewed a recent audiology evaluation is REQUIRED. If a report does not upload, take photos of the document pages and attach those images. * Allowed formats jpg, png, pdfFile* Drop files here or Select files Accepted file types: jpg, png, pdf, Max. file size: 384 MB. * Do not attach an electronic mapPhoneThis field is for validation purposes and should be left unchanged.
