Former Students Of NS Schools For The Deaf Class Action Intake Form (detailed form)

Please note: we will keep confidential any personal identifying information that you provide on this form, subject to first receiving permission from you.

Please complete this form if you wish to be kept informed of the progress of this case.

Completing this form creates no financial obligation for you. It does not create a lawyer/client relationship between yourself and Wagners (or any of its lawyers).

By completing this form you are asking Wagners to include you in our list of potential members in this class action, but our firm is not agreeing to represent your personal interests. Wagners will represent the interests of the class as a whole.

The definition of the class of people included in this class action may in the future change or be modified. We may not inform you or the public if and when the class definition changes. It is your responsibility to ensure that your own personal interests and legal rights are being protected. You may wish to obtain independent legal advice in order to determine whether it would be in your best interest to pursue independent litigation in this matter. Should you meet the definition of a class member, you may be entitled to compensation if there is a final judgment or settlement in favour of the class. However, the class definition may change over time, and there is no guarantee of compensation regardless of the class definition.

FORMER STUDENTS OF NS SCHOOLS FOR THE DEAF

CLASS ACTION INTAKE FORM

THIS FORM IS FOR INFORMATIONAL PURPOSES ONLY. IT IS NOT A CLAIM FORM AND DOES NOT GUARANTEE ELIGIBILITY FOR ANY EVENTUAL COMPENSATION.
Date:*
MM slash DD slash YYYY
Claimant's Name:
Individual who attended/resided at:

(i) the School for the Deaf, Halifax, Nova Scotia; and/or (ii) the Atlantic Provinces Special Education Authority – Resource Centre for the Hearing Impaired/Handicapped (originally the Interprovincial School for the Education of the Deaf), Amherst, Nova Scotia
Name
First Middle Last
Other names Claimant may be known as, if any (including maiden name, if applicable):
Name
First Middle Last
Name
First Middle Last
Date of Birth:
MM slash DD slash YYYY
Place of Birth:
Claimant’s Mailing Address:
Address:
Email:*
Skype:
Home Phone:
Cell Phone:*
Other Phone:
Facsimile:
Claimant’s Preferred Form of Contact:
Email*
Reg. Mail:
Text:
Skype:
Contact Person (If Other Than Claimant) and His/Her Contact Information:
Name
First Last
Relationship to Claimant:
Address (Mailing):
Email*
Skype:
Home Phone:
Cell Phone:*
Other Phone:
Facsimile:
Preferred form of contact:
Email*
Reg. Mail:
Text:
Skype:
Claimant’s Marital Status:
Status
Single: Married: Common Law:
Status
Divorced: Widowed: Separated:
Date
Divorce Date: Widowed Date: Separated Date:
Parents:
Biological Father: Biological Mother:
Period of Residency/Attendance:
Period of time at the School for the Deaf (Halifax, Nova Scotia)
From To
Period of time at the Atlantic Provinces Special Education Authority – Resource Centre for the Hearing Impaired/Handicapped (originally the Interprovincial School for the Education of the Deaf) (Amherst, Nova Scotia)
From To
The reason(s) you were placed at the institution(s) (i.e. hearing and/or visual impairment):
A detailed description of your experiences at the above institution(s):
Physical
Psychological
Sexual
A detailed description of any complaint(s) you have made to date regarding mistreatment or abuse sustained at the above institution(s), any responses taken, the date of the complaint and the name of the individual(s) involved.
Complaint:
Any response to complaint:
Individual(s) complained of:
Date of complaint:
MM slash DD slash YYYY
Thank you for completing this informational form. Upon receiving your contact information, we will add you to our database and will provide you with any relevant updates on the action. Please note that individual interviews and meetings are not required at this time.

Single:	Married:	Common Law:

Divorced:	Widowed:	Separated:

Divorce Date:	Widowed Date:	Separated Date:

Biological Father:	Biological Mother:

Former Students Of NS Schools For The Deaf Class Action Intake Form (detailed form)

FORMER STUDENTS OF NS SCHOOLS FOR THE DEAF

CLASS ACTION INTAKE FORM

Claimant's Name:

Other names Claimant may be known as, if any (including maiden name, if applicable):

Claimant’s Mailing Address:

Claimant’s Preferred Form of Contact:

Contact Person (If Other Than Claimant) and His/Her Contact Information:

Preferred form of contact:

Claimant’s Marital Status:

Parents:

Period of Residency/Attendance:

Period of time at the School for the Deaf (Halifax, Nova Scotia)

Period of time at the Atlantic Provinces Special Education Authority – Resource Centre for the Hearing Impaired/Handicapped (originally the Interprovincial School for the Education of the Deaf) (Amherst, Nova Scotia)

A detailed description of your experiences at the above institution(s):

A detailed description of any complaint(s) you have made to date regarding mistreatment or abuse sustained at the above institution(s), any responses taken, the date of the complaint and the name of the individual(s) involved.