Rosen Family Preschool, Hearing Speech and Deaf Center Online Registration

Registration

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Thank you for your interest in Early Childhood Education at Seattle's Hearing Speech and Deaf Center! Please complete this form to apply for enrollment. We will set up a follow-up appointment to review your child's placement in our program.

If you have any questions, please reach out to us at rosenpreschool@HSDC.org.

* denotes required fields

Referral Information

How did you hear about us?

Referral Name

Family Information

Account Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info*

Please list name and age of sibling(s)*

List Home Language(s)*

Any interpreting requests?

Any accessibility needs?

VP Number:

Special skills or interests: *

Contact #1

First Name*

Last Name *

How Can We Contact You?

Home Phone *

Work # *

Cell # *

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

First Name

Last Name

How can we contact you?

Home Phone

Work #

Cell # *

Email* (Emails are kept confidential)

Confirm Email*

Student #1

Student's First Name*

Last Name*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size

Any chronic or life-threatening illnesses we should be aware of?*

Grade Level*

Please share student's accessibility needs:*

Why are you interested in our program?*

How does your child identify: Deaf/Hearing/HH/KODA/SODA/Unilaterally Deaf/Other*

Allergies & Dietary Restrictions*

Medications*

Physician Name and Phone/Dentist Name and Phone*

Immunization Notes*

Student's Primary Language*

Home School District*

Do you have an IEP /IFSP?*

Do you use ASL at home? *

Is child Deaf/hard of hearing?*

Please click on the Search button below, then choose the class you want.

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size

Any chronic or life-threatening illnesses we should be aware of?*

Grade Level*

Please share student's accessibility needs:*

Why are you interested in our program?*

How does your child identify: Deaf/Hearing/HH/KODA/SODA/Unilaterally Deaf/Other*

Allergies & Dietary Restrictions*

Medications*

Physician Name and Phone/Dentist Name and Phone*

Immunization Notes*

Student's Primary Language*

Home School District*

Do you have an IEP /IFSP?*

Do you use ASL at home? *

Is child Deaf/hard of hearing?*

Please click on the Search button below, then choose the class you want.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size

Any chronic or life-threatening illnesses we should be aware of?*

Grade Level*

Please share student's accessibility needs:*

Why are you interested in our program?*

How does your child identify: Deaf/Hearing/HH/KODA/SODA/Unilaterally Deaf/Other*

Allergies & Dietary Restrictions*

Medications*

Physician Name and Phone/Dentist Name and Phone*

Immunization Notes*

Student's Primary Language*

Home School District*

Do you have an IEP /IFSP?*

Do you use ASL at home? *

Is child Deaf/hard of hearing?*

Please click on the Search button below, then choose the class you want.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size

Any chronic or life-threatening illnesses we should be aware of?*

Grade Level*

Please share student's accessibility needs:*

Why are you interested in our program?*

How does your child identify: Deaf/Hearing/HH/KODA/SODA/Unilaterally Deaf/Other*

Allergies & Dietary Restrictions*

Medications*

Physician Name and Phone/Dentist Name and Phone*

Immunization Notes*

Student's Primary Language*

Home School District*

Do you have an IEP /IFSP?*

Do you use ASL at home? *

Is child Deaf/hard of hearing?*

Please click on the Search button below, then choose the class you want.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size

Any chronic or life-threatening illnesses we should be aware of?*

Grade Level*

Please share student's accessibility needs:*

Why are you interested in our program?*

How does your child identify: Deaf/Hearing/HH/KODA/SODA/Unilaterally Deaf/Other*

Allergies & Dietary Restrictions*

Medications*

Physician Name and Phone/Dentist Name and Phone*

Immunization Notes*

Student's Primary Language*

Home School District*

Do you have an IEP /IFSP?*

Do you use ASL at home? *

Is child Deaf/hard of hearing?*

Please click on the Search button below, then choose the class you want.

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Credit Card

Card Number

Exp Month

Exp Year

Card Nickname

Name as it appears on card

Address Line 1

Address Line 2

City

State

Zip

Registration

Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

Required Policies and Agreements (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Credit Card

Required Policies and Agreements

(Show-Hide Details)