Baker Scholars Program Registration Form - EN

Baker Scholars Program

Registration Form
The Baker Scholars Program supports families who have limited access to listening and spoken language intervention services. The Baker Scholars Program delivers parent coaching and direct therapy services so that children with cochlear implants can learn to listen and speak, regardless of the family's geographic proximity to appropriate services.

Parents are key participants in this process. To achieve the combined family and Baker Scholars Program goals for your child to reach his or her maximum potential in the areas of listening and spoken language development, your family must commit considerable time and effort to attending therapeutic sessions weekly and daily practice of the weekly therapeutic skills taught with your child. A parent or guardian must be present and participating in all sessions alongside your child.

This program is supplemental to any other educational and therapeutic services your child may already be receiving or may be eligible to receive in the future.

Please upload the following documents:

Copy of your child’s most recent hearing test results (aided audiograms preferred)
Copy of IEP (Individual Education Plan)
Copy of any other current related reports

Your Child
Child Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Year attended ListenToMe!
Parents
Parent 1*

First NameLast Name
Parent 1 Email*
example@example.com
Parent 1 phone number*
Please enter a valid phone number.Format: (000) 000-0000.
Parent 1 alternate phone number
Please enter a valid phone number.Format: (000) 000-0000.
Parent 2

First NameLast Name
Email
example@example.com
Parent 2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Technology access
Do you have a computer/ tablet with a webcam that can be used for video conferencing?*

YesNo
Do you have internet services to support video conferencing?*

YesNo
How comfortable are you using FaceTime or Zoom?*

Not at allSomewhatVery Comfortable