Families Quarterly Meeting Registration
May 29th, 2024 - 12:00PM- 1:00PM Sponsored by: Ohio Department of Health under the Infant Hearing Family Outreach Program and the Ohio Coalition for the Education of Children with Disabilities - ODH project number CSP006336
Which Meeting are your registering for?
*
Please Select
May 29th, 2024
Email
*
if you don't have an email use noemail@ocecd.org
Attendee Name
*
First Name
Last Name
Back
Next
City/Town
*
State
*
County
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
zip/postal code
*
Please enter additional parent or guardian contact information
*
No additional parent/guardian
Add additional parent/guardian information
Back
Next
Additional Contact Information
Please enter parent or guardian contact information if different from above
Full Name
First Name
Last Name
Email
if you don't have an email use noemail@ocecd.org
Back
Next
City/Town
State
County
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
zip/postal code
Please enter parent or guardian contact information if different from above
No additional parent/guardian
Back
Next
Child Information
This early intervention event is geared to families with children 0-3, but families with children up to age 5 are permitted to attend.
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Is your child (family) currently receiving Part C Early Intervention Services through the Department of Developmental Disabilities (DODD)?
*
Yes
No
Referred but not enrolled
Not Sure
Is there an additional children information you would like to add?
*
No additional children
Add additional children
Back
Next
Additional Child Information
This early intervention event is geared to families with children 0-3, but families with children up to age 5 are permitted to attend.
Child's Name
First Name
Last Name
Child's Date of Birth
-
Month
-
Day
Year
Date
Is your child (family) currently receiving Part C Early Intervention Services through the Department of Developmental Disabilities (DODD)?
Yes
No
Referred but not enrolled
Not Sure
Please enter parent or guardian contact information if different from above
No additional parent/guardian
Back
Next
What is the primary language used in the home?
*
Please Select
English
Spanish
American Sign Language
Arabic
Chinese
French
German
Italian
Nepali
Russian
Somali
Ukrainian
Other
ASL Interpreters and captioning will be provided. Please let us know if you need additional accommodations below:
Submit
Should be Empty: