Resource Services - Outreach Program

Please be sure to follow up and fax a copy of the child's audiogram to (519) 453-3044.

Consent *

I consent to sharing my child's name, date of birth, identification status and contact information with PDSB. I understand that I can opt out from these services at any time.

I give my consent

Created At

Regional Infant Hearing Program *

SUBMITTED BY

First Name *

Last Name *

Job Title/Position *

If other job title/position, please specify

Child's First Name *

Child's Last Name *

Child's Date of Birth *

Has there been a diagnosis by an Audiologist? *

Yes

If yes, what year?

Parent/Guardian First Name *

Parent/Guardian Last Name *

French Language Services Required? *

Yes

Interpreter Required? *

Yes

If interpreter required, please enter language

Address *

City *

Province *

Postal Code *

Phone *

Phone 2

Email *

Re-Enter Email *

ADDITIONAL INFORMATION/CONCERNS

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