JOHN TRACY CLINIC 806 W. Adams Blvd. Los Angeles, CA 90007 (800)522-4582 FAX (213)745-5074 Distance Learning - pals@jtc.org

1. START HERE

FAMILY INFORMATION

IMPORTANT!! If your child is 24 months to five years old, please click here to register.

If your child is 23 months or younger, please continue to fill the form out below.

* I want to enroll in the Distance Education Course for Parents

Yes, I will access the lessons online

No, I need lessons sent by mail

Father/Guardian First Name

Middle Name

Family Name

Mother/Guardian First Name

Middle Name

Family Name

Address

City

State

Postal Code

Country

Phone Number

* E-Mail Address

Father's Occupation

Mother's Occupation

Language(s) spoken at home

CHILD'S HEALTH AND HEARING HISTORY

Child's First Name

Middle Name

Family Name

Sex

Male

Female

* Date of Birth:

Was your child premature?

Yes

If Yes, how many months

Was your baby healthy at birth?

Yes

Is your child healthy now?

Yes

List disabilities or special needs of your child

Ongoing medical treatment:

Is there a history of childhood hearing loss in the family?

Yes

Has your child had recent hearing tests?

Yes

If yes, please send copy

Age at onset of hearing loss

Age at diagnosis

Degree of loss

Cause, if known

What sounds, if any, your child hears:

With amplification

Without amplification

Check any devices your child is now using:

Cochlear Implant

Model/Type

Side:

Left

Right

Bilateral

Hearing Aid

Model/Type

At what age did your child start using it consistently?

DEVELOPMENTAL CHECKLIST (Check all that apply)

Current concerns about your child

OTHER CHILDREN'S NAMES AND BIRTHDATES

Name

Sex

Male

Female

Date of Birth

Name

Sex

Male

Female

Date of Birth

Name

Sex

Male

Female

Date of Birth

ADDITIONAL INFORMATION

How should greetings of your letters be written?
Examples: Dear Ms. Last Name Dear First Name(s) Dear Mr. and Mrs. Last Name

Write your preference

How did you find John Tracy Clinic?

Referral from Professional

Internet Search

Suggestion from Parent/Friend

Other

PHOTOGRAPHIC RELEASE FORM

Date

I give permission to John Tracy Clinic to use:

Pictures of me and my minor child(ren)

Portions of my written comments (with initials or first name only)

in the publication and promotion of educational materials without limitation or reservation.

Check this box for electronic signature

I agree to above statements

If you want to get a copy of this completed form thru e-mail,
please enter your e-mail address below

* Enter the word in the image
captcha

* Indicates Response Required

Speech/Language	Audiology	Education	Physical/occupational therapy
other

Left	Right	Bilateral	Bone Conduction
BAHA	Body	Other