Permissions to Share Info for DHH (w/ vision)

What is your role?

Family MemberProfessional (e.g. Teacher)
Is your child/student in Early Intervention (EI) or School Age?

Early Intervention (EI)School Age

Release of Information to Receive Resources that Support Children with Hearing, Vision, or Hearing and Vision Concerns
Welcome to school age special education services! Students who have hearing, vision, or hearing and vision concerns have unique linguistic, environmental, and cultural needs. This form is very important to make sure that families of children who have these concerns have appropriate information as they transition from pre-school to school age special education services.

Within the Pennsylvania Department of Education, the Bureau of Special Education (BSE) and the Bureau of Early Intervention Services (BEIS) work together to provide supports and services to children and families of children with these concerns. They support families with a variety of resources as students transition to school age programs. Working with the BSE and BEIS, the Pennsylvania Training and Technical Assistance Network (PaTTAN) provides a full array of resources targeted to improving student results.

The purpose of this form is to establish a continuation of information and support to families with children who have hearing, vision, or hearing and vision concerns from early intervention into the school system. If you are interested in receiving information and resources from PaTTAN that will assist you in supporting your child, (such as IEP development, accommodations, specially designed instruction, etc.), please complete the following information and submit the form to PaTTAN. PaTTAN will keep all information you provide on this form confidential.

If you have any questions, please contact Erin Campion at ecampion@pattan.net.
Release of Information to Receive Resources that Support Children with Hearing, Vision, or Hearing and Vision Concerns
Welcome to the Family Resource Group!

All families of children who are deaf or hard of hearing (DHH), blind or visually impaired (BVI), or deaf-blind (DB) are invited to sign up for the PaTTAN Family Resource Group.

The goal of this group is to send out resources, event information, and contacts that would benefit your family and your child.

The Family Resource Group is for families and children (DHH, BVI, DB) that are moving from Early Intervention (EI) and Pre-School into school AND for families and children (D/HH, BVI, DB) who are already in school.

Your information will not be shared outside of the PaTTAN Initiatives. We do not need any identifying information about your child. Information will be grouped according to your area of interest (DHH, BVI, or DB) and you can unsubscribe at any time.

This is a way for us to send up-to-date resources, opportunities, and connections directly to your family.

Join the list, so we can connect you with the appropriate team members. Sign up now and the emails will be in your inbox.

If you have any questions, please contact Erin Campion at ecampion@pattan.net.
Section 1
Parent/Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
My child has a:*

hearing concernhearing and vision concernvision concern
Section 2
As the parent/guardian of a minor child, I voluntarily provide PaTTAN the information in SECTION 1 above. I understand that PaTTAN will keep the information about my child and family in a confidential manner. I understand that:

I am providing my information voluntarily;
I understand the information on this form; and
I have the right to withdraw my consent to PaTTAN maintaining this information at any time.
Type Your Full Name*
Should be Empty:

Release of Information to Receive Resources that Support Children with Hearing, Vision, or Hearing and Vision Concerns

Release of Information to Receive Resources that Support Children with Hearing, Vision, or Hearing and Vision Concerns

Section 1

Section 2