DELTA - Summer School Application

Summer School 2007 Application

Please complete this form and click submit at the bottom of the page.
(items marked with a * are required)

Place Lancaster

Programme Pre-school
Primary

Name of Adult 1 *

Name of Adult 2 *

Address *

Town *

County

Postcode *

Telephone *

Mobile

Email Address *

Name BoyGirl

Date of birth

Hearing loss ProfoundSevereModerate

Diagnosed in

Hearing aids Type

Cochlear implant Being assessedFitted

Centre

When

Communication method Auditory OralTotal CommunicationSign LanguageOther Other

Child 2

Name BoyGirl

Date of birth

Child 3

Name BoyGirl

Date of birth

Child 4

Name BoyGirl

Date of birth

Is there anything else you
feel would be relevant?