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Registration for Social Skill and Self-Advocacy Group for Children with Hearing Loss
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Email
*
Your email
Child's First Name, Middle Initial, Last Name
*
Your answer
Child's Date of Birth
*
MM
/
DD
/
YYYY
Child's Primary Home Address
*
Your answer
Child's Grade in School 2020-2021
Your answer
Father's First Name, Last Name
*
Your answer
Father's Email
Your answer
Father's Cell Phone Number
Your answer
Mother's First Name, Last Name
*
Your answer
Mother's Email
*
Your answer
Mother's Cell Phone
*
Your answer
Does your child primarily communicate using spoken English?
Yes
No
Yes, with support
Other:
What would you like your child to gain from participating in a group like this?
Your answer
How did you hear about this social group?
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Web Search
Word of Mouth
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