Juice Box Conversations (Learner)

Juice Box Conversations

Our Lived Experience (DHH)
Online learning programs are for students who qualify for APSEA services. Registration must be completed by their APSEA Education Support Teacher (EST).
Education Support Teacher Name:*

First NameLast Name
Education Support Teacher Email Address:*
example@example.com
Student Information
Student Name:*

First NameLast Name
Grade:*
If Other, please specify grade:*
City/Town:*
Province:*
Communication Mode:*
School Information
School District/Regional Centre for Education*
School Name:*
School Team Contact Name:*
School Team Email Address:*
example@example.com
School Team Member Role:*
If Other, please specify:*
Is the above school contact facilitating participation in this virtual program?*

YesNo
If no, please identify who is responsible for ensuring the learner is adequately set up to participate in this program?
Full Name:*
Email Address:*
example@example.com
Date and Time
Please specify a date and time that works for your class:
An APSEA staff member will follow up to confirm a date/time and finalize details.
Feedback
How did you hear about this program?*
If Other for how you found out about this program, please specify
Should be Empty:

Juice Box Conversations