Services Permission Form
To participate in services at the BC Family Hearing Resource Society (BCFHRS), please sign below.
I give permission to the BCFHRS to provide services to my child and family.
*
Yes
No
I give permission for our family to receive BCFHRS information updates electronically.
*
Yes
No
If you have any emergency contacts for your family, please enter their information below:
-
Area Code
Phone Number
Relationship to you:
Phone Number:
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Area Code
Phone Number
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
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Month
-
Day
Year
Date
Name of parent/legal guardian filling this form
*
First Name
Last Name
Today's Date
*
-
Month
-
Day
Year
Date
Signature
*
If you wish to be sent a digital copy of this form, please enter your email address here.
example@example.com
Submit
Submit
Should be Empty: