Youngstown Hearing & Speech Center

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Name:
Address:
City:
State:
Zip:

Deaf / Hard of Hearing
Youth Activities Survey

1	Person completing this form:
	Parent:	Student:	Both:	Student Age:
	Educator:	Director of Education:	Director of Special Education:


2	Do you feel that a Deaf/Hard of Hearing Youth Program would be something you would be interested in?
	Yes:		No:


3.	Are you willing to help transport / drop off and pick up your child?
	Yes:		No:


4	Would you the parent be willing to volunteer?
	Yes:		No:


5	If you (parent) are interested in volunteering, how much time are you willing to invest?


6	What type of activities would be helpful to you? Please rate using the following scale:

Instruction in American Sign Language
	Very Important	Important	Not Important

Homework Assistance
	Very Important	Important	Not Important


Speakers of Deaf and Hard of Hearing adults that are successful adult role models
	Very Important	Important	Not Important



Providing fun activities such as bowling, going to sporting events, plays etc.
	Very Important	Important	Not Important

7	How will this program benefit you if your child is either hard of hearing, deaf or a child of a deaf adult (CODA)?

8	Comments or Suggestions: