FCDHHC - ASL-Only Services Permission Form

ASL Services Permission Form

For Families receiving primary services from Children's Hearing and Speech Centre of BC (CHSC)
To participate in American Sign Language (ASL) services at the Family Centre for Deaf and Hard of Hearing Children (FCDHHC), please complete the information and sign below.
Child's Name

First NameLast Name
Child's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please confirm that the Family Centre for Deaf and Hard of Hearing Children (FCDHHC) is the main organization providing early intervention services to your family?
What services do you receive from CHSC?

Other
Please tell us the name of the Early Interventionist providing services to your family:
Please tell us the name of the Early Intervention group(s) your child attends:
I give permission to the FCDHHC to provide ASL services to my child and family.
I give permission to FCDHHC to send information updates electronically to my family:
Name of parent/legal guardian filling out this form

First NameLast Name
Email address
example@example.com
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty:

ASL Services Permission Form