Empower Me - Enrolment Form and Pre-Program Survey

Empower Me is a workshop designed for carers and extended family members of children with any degree of permanent hearing loss, who wish to learn more about hearing loss and how to support the child to achieve their full potential.

The aim of these workshops is to develop capacity and resilience in the child’s network through education about hearing loss, with a focus on applying this knowledge to the specific needs of the individual child with whom they are connected.

First Name of Child: *

Last Name of Child: *

Child's Date of Birth * +

Where do you usually access our services? *

Where would you like to attend the Empower Me Group? You can attend at your centre of choice or by Teleintervention: *

First Name of Parent 1: *

Last Name of Parent 1: *

First Name of Parent 2: *

Last Name of Parent 2: *

Best Contact Email: *

Best Contact Phone Number: *

How many parents will be attending? *

How many extended family members will be attending? (excluding primary carers) *

First Name of 1st extended family member: *

Last Name of 2nd extended family member: *

1st extended family member's relationship to child: *

Best Contact Email: *

First Name of 2nd extended family member: *

Last Name of 2nd extended family member: *

2nd extended family member's relationship to child: *

Best Contact Email: *

First Name of 3rd extended family member: *

Last Name of 3rd extended family member: *

3rd extended family member's relationship to child: *

Best Contact Email: *

First Name of 4th extended family member: *

Last Name of 4th extended family member: *

4th extended family member's relationship to child: *

Best Contact Email: *

First Name of 5th extended family member: *

Last Name of 5th extended family member: *

5th extended family member's relationship to child: *

Best Contact Email: *