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Online Family ASL Tutoring Program Registration

Regsister for Online ASL Tutoring

Thank you for your interest in learning American Sign Language! If you live in Northern California and have a Deaf or Hard of Hearing child you may be eligible for free ASL classes. Please fill out this form to the best of your ability and we will be in contact with you.

1. Contact Info *This question is required.

First Name

Last Name

Street Address

Apt/Suite/Office

City

State

Zip

County

Email Address

Your Gmail address (if you have one already) You will be asked to get one.

Phone Number

Mobile Phone

2. How did you learn about the Online ASL tutoring program?

3. My Family; Please list family members interested in learning sign language. Estimate the number of signs they know. (Basic 0-50 words, Beginner 75-150, Beginner Intermediate 150-500, Intermediate 500-1500, Advanced 1500+ words)

Name

Skill Level/# of signs

Name

Skill Level/# of signs

Name

Skill Level/# of signs

Name

Skill Level/# of signs

4. Deaf/Hard of Hearing Child

First Name

Last Name

Age / Date of Birth

Current School /Early Start Program Teacher

Special needs?

5. Second Deaf/Hard of Hearing Child

First Name

Last Name

Age / Date of Birth

Current School /Early Start Program Teacher

Special needs?

6. My Family: Please prioritize from 1-7 by level of importance, to your family "My deaf or hard of hearing child's ability to . . . .". You can only use each number once. We realize that the items ranked 5, 6, & 7 may still be important to you, however it is helpful to know how the items compare in importance. Note: for the following table each column is restricted to a single answer across all rows.

Ability to read at age level
Ability to write well
Ability to speak and be understood
Ability to sign
Confidence
Ability to make friends
Ability to communicate with extended family

7. Family Communication: Please rate how often you use these strategies to communicate with your child?

Space Cell	1 Rarely	2	3 Sometimes	4	5 Frequently
Sign
Gesture
Speaking
Speaking with lip movements
Writing or drawing
Giving up

8. Utilizing any and all strategies that you know for communication.

Space Cell	1 Never	2	3 Sometimes	4	5 Always
How often do you understand what your child is communicating to you?
How often does your child understand what you are communicating to him or her?
How often do you feel like you cannot sign what you want to say?
Have you ever attended any activities in the Deaf community?

9. Book Reading with Your Child

Space Cell	1 Never or almost never	2	3 Once a week	4	5 Several times a week
How often do you read a book with your child without signing?
How often do you read a book with your child using signs?
How comfortable do you feel reading a book using signs to your child?
How often do you watch signed stories on video/DVD?

10. Please rate your level of comfort communicating with Deaf adult.

Space Cell	1 Uncomfortable	2	3 Somewhat	4	5 Comfortable
How comfortable do you feel about your ability to communicate in sign with a Deaf adult?
How comfortable are you communicating in other ways which a Deaf adult? (writing, gesturing, texting, email)

11. Family: How much do you know about these resources?

Space Cell	No Knowledge	Some Knowledge	Know or Own or Use
Alerting Devices (i.e. flashing lights for the phone, doorbell, alarm clock)
American Sign Language (ASL)
Family and Adult ASL Classes
Closed Captioning on TV & Videos
Deaf History
Bilingual American Sign Language &English Education
Videophones
Video Relay Services (VRS)
Sign Language Interpreting Services

12. Estimate the number of signs your child understands This question requires a valid number format.

13. Estimate the number of signs your child produces This question requires a valid number format.

14. Estimate the number of spoken English (or other language) words your child understands This question requires a valid number format.

15. Estimate the number of English (or other language) words your child speaks This question requires a valid number format.

16. Your Deaf/HH Child; Please rate your deaf or hard of hearing child on the following:

Space Cell	1 Rarely	2	3 Sometimes	4	5 Frequently
Shows curiosity
Ability to imitate people
Tendency to initiate interaction
Likes to follow routines
Responds to auditory input
Tracks movements with eyes
Notices facial expressions
Maintains good eye contact
Easily warms to new people

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

1st choice
2nd choice
3rd choice

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

19. Would you be willing to get a free Gmail address which allows us to use Google Hangouts as the video phone?

20. I understand that my class will succeed best when there are no distractions. I will try to minimize distractions by: Ignoring phone calls, Turning off TV and music in the same room, and Having other children, people, pets occupied in another area

21. I will inform my instructor of class cancellation at least 24 hours ahead of time. If I do not show for a total of 3 (three) times of classes without reason or without informing ahead, future classes will be cancelled (so instructor can serve other students in waiting).

22. I will take a post-test at the end of my tutoring sessions.

23. Terms of Agreement I agree to the terms and conditions outlined. (Please type your name below)

24. Thank you! We will be in contact to connect you with your tutor. Feel free to leave your comments or additional information you think we should have.

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