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Deaf/Hard of Hearing Adult Involvement School-Age Mentor (SAM) Services
School/District/Cooperative Name
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Federal Tax ID Number
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Contract Invoice Address
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City
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Country
LEA DIrector Name
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Last
Phone Number
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Email
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Contract Signatory Name
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First
Last
Phone Number
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Email
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Deaf/Hard of Hearing Adult Involvement School-Age Mentor (SAM) Scope of Services
Services
Provide direction instruction and/or consultative services to the student and/or the student's family.
Provide appropriate academic and social support to children who are deaf and hard of hearing.
Assist families of children who are deaf and hard of hearing to access resources in a timely manner.
Attend case conferences as requested.
Training
Educate professionals who work with students who are deaf and hard of hearing.
Provide self-advocacy, social, and secondary transition training to students.
Assist deaf and hard of hearing students in establishing a positive identity.
Communication
Collaborate with school staff.
Communicate with student and family.
Report on student progress.
Provide Summary of Service documentation to specified recipients after services have been rendered.
Additional Deaf/Hard of Hearing Adult Involvement School-Age Mentor (SAM) Services
The Center for Deaf and Hard of Hearing Education (CDHHE) can additionally provide the following services. Please check the services and responsibilities that you expect from the School-Age Mentor (SAM):
Meeting style
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In-person
Virtual/Remote
Location
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school
home
community
other
Provides DHH student(s) with support regarding:
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language/literacy model (please complete Indiana CDHHE Communication Plan)
social/emotional
self-identity
Deaf Culture
community experiences
transition coaching
self-advocacy
ASL instruction
using CART services
using an interpreter
using a notetaker
Provide DHH student's family with support regarding:
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language
social/emotional
Deaf Culture
community experiences
transition
self-advocacy
ASL instruction
Provide school staff with support (in-servicing/training/professional development) regarding:
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language
understanding DHH student social/emotional needs
Deaf Culture
provision of community experiences
provision of self-advocacy
Deaf/Hard of Hearing access
ASL storytelling
other specific student needs
Name of person filling out the form
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Date
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