Please fill out this form. This information is entirely confidential.

The following information will assist us in understanding your child and family's needs.

Please include information about the child’s parents and/or legal guardians

Our program strives to respect diversity. If you think it will help us better serve your family, please provide the following optional information:

For us to best serve your family, it is helpful if you can share the following information.

FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY ACT (FOIPPA): The information requested on this form is collected under the authority of section 26(c) of the Freedom of Information and Protection of Privacy Act (FOIPPA). The information provided will be used only to facilitate the operation of our services/programs and is in compliance with the FIPPA. If you have any questions about the collection of your personal information, please contact us. Our head office address is 15220, 92nd Avenue, Surrey, BC V3R 2T8. You can also contact us by phone at 604-584-2827 (or toll-free at 1-877-584-2827), or by email at info@bcfamilyhearing.com.