Parental Consent Form

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.*

YesNo
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.*

YesNo
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.*

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

YesNo
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.*

YesNo
Parent Name*

First NameLast Name
Parent Signature*

Clear
Date*

MonthDayYear
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!
Should be Empty: