Family Matters! Registration Form

First Name *

Last Name *

Date of Birth *

What is your current position

Email Address *

Address

Street Number & Name *

City *

State *

Zip Code *

On the day of the workshop, what is the best telephone number to reach you at (in case of inclement weather, etc)?

*

Snacks, beverages and lunch will be provided. Please indicate any dietary restrictions:

*

None

Vegetarian

Gluten Free

No ham, pork or gelatin

Nut food allergy

I have dietary restrictions not listed above and will bring my own food for the day.

To help us find the best fit for each volunteer, please indicate which of the following groups you are comfortable or have experience with in communicating in American Sign Language (ASL). Certified ASL interpreters will also be onsite at the workshop.

*

Babies and Toddlers, ages 0-3

Youth, ages 4-11

Teens, ages 12-18

Adults, ages 18+

No ASL experience

How would you like to help the day of the workshop? Please select your top two preferences. We will do our best to accommodate requests.

*

Childcare Assistants: Help take care of our littlest attendees by lending a hand in the childcare room under the supervision of licensed childcare providers.

Lead Classroom Teacher*: Lead activities for 20 children who are D/HH or typical hearing siblings. Schedules are to include pre-planned activities and free-time to be planned by the teacher. *Certified Teacher of D/HH or TC - D/HH preferred.

Classroom Assistants: Each classroom will have up to 20 children led by a teacher of the Deaf/Hard of Hearing. Classrooms will include children who are DHH and siblings with typical hearing. Volunteers will assist teachers as needed throughout the day.

Wherever you need me!

Please read the information for the PERMISSION TO PERFORM A BACKGROUND CHECK: below and click the box below to agree.

You have agreed to participate in an event that involves minor children or teens. To ensure that these programs are supported by qualified adults in a safe and secure environment, all adult program or event faculty, staff, students and volunteers are required to complete a background screening before they begin working with children.

I hereby authorize Family Matters! and/or its agents to make investigation of my background, references, character, past employment, consumer reports, education, and criminal history record information which may be in any state or local files, including those maintained by both public and private organizations, and all public records, for the purpose of confirming the information contained on my application and/or obtaining other information which may be material to my qualifications to participating in this event.

*

Please read the information below for the CONSENT TO PHOTOGRAPH/VIDEO AND USE. If you agree to the terms listed below, please click the box beneath to consent.

I give Michigan Medicine permission to release photographs, videos, electronic or other media involving me and members of my family registered for the Family Matters! Workshop. The items may be released to any radio, television, internet, social media, print or other media outlet. The items may be used by its public relations and marketing units and by the media indefinitely for educational, promotional, public relations, or marketing purposes. This authorization has no expiration date; but I understand that I can revoke this permission at any time by contacting Michigan Medicine Pediatric Audiology at (734) 998-5589. However, I also understand that Michigan Medicine has no control over disclosures made outside Michigan Medicine before I revoke my permission. I understand this permission is voluntary. I do not have to release my information, and whatever I decide will not affect my family’s participation in the Family Matters! workshop. *

Thank you for volunteering! We look forward to seeing you on March 11. A few weeks before the event, you will receive additional details about the workshop, such as when to arrive, what to wear, how you will be helping.

If your availability changes between now and the conference, please update us by email at otopedaudio@gmail.com.

Volunteer Registration Form

Address

Please read the information for the PERMISSION TO PERFORM A BACKGROUND CHECK: below and click the box below to agree.

Please read the information below for the CONSENT TO PHOTOGRAPH/VIDEO AND USE. If you agree to the terms listed below, please click the box beneath to consent.

Volunteer Registration Form