FCDHHC - Services Permission Form

Services Permission Form
To participate in services at the Family Centre for Deaf and Hard of Hearing Children, please sign below.
I give permission to FCDHHC to provide services to my child and family.
I give permission for our family to receive FCDHHC information updates electronically.
If you have any emergency contacts for your family, please enter their information below:

Area CodePhone Number
Relationship to you:
Phone Number:

Area CodePhone Number
Child's Name

First NameLast Name
Child's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of parent/legal guardian filling this form

First NameLast Name
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
If you wish to be sent a digital copy of this form, please enter your email address here.
example@example.com
Should be Empty: