Online ASL Tutor Request

Page One

Families in Northern California with Deaf/HH children ages 0-7 can learn American Sign Language online from home . Each family has weekly session with a private tutor at a convenient, pre-arranged time. You must have high speed internet and a webcam. This program is offered on a first serve-first come basis.

1. Contact Info

Parent/Guardian Name

Street Address

Apt/Suite/Office

City

State

Zip

County

Email Address

Phone Number

Mobile Phone

Video Phone #

2. About Your Deaf/HH Child(ren)

Deaf/HH Child's Name
Date of Birth
Deaf/HH Child's Name
Date of Birth

3. Languages you are currently using at home with your child:

English
American Sign Language
Spanish

4. What internet and video technology do you currently have?

High speed internet only
High speed internet and webcam
High speed internet, webcam and Google Hangouts
video phone

5. If you have a video phone already - who is your provider (i.e. Purple, Sorenson) and what is your video phone number?

6. What days and times would work best for you to meet online with your tutor?

1st choice
2nd choice
3rd choice

7. Who would be involved in the online ASl tutoring? (i.e siblings name, fathers name, mothers name, grandparents)

1.
2.
3.
4.
5.
6.

8. Do you have any questions or comments you would like to add?