Prism Centre for Audiolody and Children’s Rehabilitation

Information Request form

Name___________________ Date: 20___/___/___ Sun Mon Tue Wed Thu Fri Sat

Address__________________ City____________________

Province__________________ Postal Code ______-______

Telephone number (home) (____) ____-______ (Work) (____) ____ - ______

Email address ________________@______________.________

I am a… [ ] Client/Family Member

(Place an X inside the boxes.) [ ] Prism Centre employee

[ ] Student

[ ] Community partner

[ ] Other

Child’s name ______________________ Age ___________

Question

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Require: [ ] Overview [ ] In Depth

Date needed by 20___/____/____

Do you have Internet access? [ ] Yes [ ] No

Is this your first information request? [ ] Yes [ ] No

Delivery method preferred [ ] Pick-up [ ] Mail