Parental Consent Form

Email

example@example.com

Name of Child

First NameLast Name

I give consent for my child's school/district to release information about my child to the Kansas Deaf-Blind Project. I also agree to allow consultants from the Kansas Deaf-Blind Project to observe my child in person or online and to provide technical assistance to the school team if requested by the school team.

I give consent for the KS Deaf-Blind Project to submit my child's name and information to the Helen Keller National Center for additional services.

I give consent for the KS Deaf-Blind Project to submit my child's name and information to Families Together for additional resources and services.

Do you want Families Together to call you to discuss their resources and services they offer?

I give consent for the KS Deaf-Blind Project to release information about my child to the KS State School for the Blind and KS School for the Deaf.

Parent Name

First NameLast Name

Parent Signature

Date

Please notify or send a copy of the completed form to your childs school contact person so that they can complete the Kansas Deaf-Blind Project Certification Application. If you have any questions, please email ksdeafblind@kssdb.org

Thank you!