Little ACEs
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Child's Name
Child's Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child's Hearing Status:
Deaf
Hard of Hearing
Hearing Aids
Cochlear Implant
Notes on Child's Hearing
Communication Methods:
Some ASL
Gestures
Voice
We would like to meet:
at home
at BridgesTN or BridgesWEST office
virtually
We are available for Little ACES and a parent ASL class on (please click as many as apply):
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
We prefer (please click all that apply)
mornings
afternoons
evenings
Please pick a class:
*
Wednesday mornings
Wednesday evenings
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Pre-Class Survey
We would love to get more information about your child and your family so that we can best support you and your class. Answer as many or as few as you like!
Child's Siblings & Ages
Describe how you and your child communicate right now. What works? What doesn't?
Are you or your child receiving any other services or are you part of any other groups?
What would you like to get from this group? Is there particular information or resources that you are seeking?
Do you or your child have any food allergies?
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Media Release
I give my permission for Bridges for the Deaf and Hard of Hearing to allow photography or statements made by my child during the course of interviews to be used as part of any promotional materials, social media posts, or print/broadcast media highlighting Bridges for the Deaf and Hard of Hearing's Youth Education & Services .
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