BCFH - 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 BC Family Hearing Resource Society (BCFHRS), please complete the information and sign below.
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Please confirm that Children's Hearing and Speech Centre of BC (CHSC) is the main organization providing early intervention services to your family?*

Yes
What services do you receive from CHSC?

Individual Early InterventionGroup Early InterventionOther
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 BCFHRS to provide ASL services to my child and family.*

YesNo
I give permission to BCFHRS to send information updates electronically to my family:*

YesNo
Name of parent/legal guardian filling out this form*

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

MonthDayYear
Date
Signature*
Should be Empty:

ASL Services Permission Form