ASTra Program Family Request Page - Washington State Hands & Voices

Advocacy Support & Training (ASTra)

Our Educational Advocacy is offered to members of Washington State Hands & Voices.

To receive support, please follow the steps below.

Step 1: Become a Member

Click here to become a member

Step 2: Request Support

To request Educational Advocacy Support from an ASTra Advocate please complete the information below.

Please contact me

Parent/Caregiver Name

Child's First and Last Name

First

Last

Child's pronoun

Child'd Date of Birth

Email

Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

County

Please type in the county you reside in Washington State

Enter best day(s) and time(s) to be contacted.

Example: Saturday 10-11am OR Mondays 8-9am / Fridays 5-6pm

Best way(s) to contact me:

Phone Call
Email
Text Message
Mail

School Placement

What is your child's "school placement" (transitioning to school, general ed, resource room, DHH program, school of the Deaf, etc)?

Where does your child attend school?

What is the reason for your advocacy request?

How can we assist you?

I need information and resources I can use to prepare for and use at my next IFSP/IEP or 504 meeting.
If available, I would like to request an ASTra advocate to attend an IFSP/IEP or 504 meeting with me.

Are you receiving advocacy support from another person or agency?

Yes
No

If you are receiving additional support, please tell us from whom and may we contact them?

Child's hearing level (Left ear)

Child's hearing level (Right ear)

Type of hearing loss/difference

Hearing Technology Used

Additional Health Care Need or Condition

Please list any additional health care needs or conditions your child experiences

Child's Ethnicity

Language(s) used at home

List other language(s) used in the home

I request an interpreter in the following language

How did you learn about us?

Would you like to sign up for our e-newsletter?

Yes
No

Please leave any additional comments or information here.

ASTra Release of Liability

ASTra Advocates have been trained through the Hands & Voices ASTra Educational Advocacy Program as lay advocates. ASTra Advocates provide information and support to parents who have requested educational advocacy and support. ASTra Advocates do not provide legal advice, or represent that their advice equates to legal counsel. Nothing in the relationship between the parent requesting support and the ASTra advocate should be construed as legal advice. Hands & Voices strongly recommends that anyone seeking legal advice get an attorney.

In consideration of the provision of ASTra Advocacy services, the receipt and sufficiency of which is hereby acknowledged, do hereby release and forever discharge Washington State Hands & Voices and all its representatives, and Hands & Voices HQ and all and any of its representatives, their agents, employees, successors and assigns, and their respective heirs, personal representatives, affiliates, successors and assigns, and any and all persons, firms or corporations liable or who might be claimed to be liable, whether or not herein named, none of whom admit any liability to the undersigned, but all expressly denying liability, from any and all claims, demands, damages, actions, causes of action or suits of any kind or nature whatsoever, which I now have or may hereafter have, arising out of or in any way relating to any and all injuries and damages of any and every kind, to both person and property, and also any and all injuries and damages that may develop in the future, as a result of or in any way relating to the provision of ASTra Advocacy services by Washington State Hands & Voices.

It is understood and agreed that the provision of services is made and received in full and complete settlement and satisfaction of the causes of action, claims and demands mentioned herein; that this Release contains the entire agreement between the parties; and that the terms of this Agreement are contractual and not merely a recital. Furthermore, this Release shall be binding upon the undersigned, and his respective heirs, executors, administrators, personal representatives, successors and assigns. This Release shall be subject to and governed by the laws of Washington State.

The ASTra Release of Liability above has been read and fully understood

Yes
No

Sign below if you agree with the ASTra Release of LIability

Type name

Date / Time

Date

Time

NOTE: All information provided will be kept confidential. We will not disclose your personal information to a third party without your consent, unless we are required or authorized to do so by law or other regulation.