The HEAR to Learn Center
The HEAR to Learn Center
The HEAR to Learn Center

 

Survey


We'd like to gather some information about our visitors. Please take a moment to complete the survey form below. All fields must be filled in. If a field is not applicable or you have no answer, please enter 'N\A'. Thank you for your time.

First

Last

Email Address

Re-type Email Address

Age of child

Age of diagnosis

Level of hearing loss

What kinds of hearing aids

Cochlear implant?

No    Yes

Public school

Grade

Class size

FM

Services

IEP

504

Happy?

Special concerns and questions

Attention span in school

Focusing in school

Diligence in school

The HEAR to Learn Center

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