Be Counted! Deaf and Hard of Hearing 50+
ASL Version here:  Be Counted! 

Are you 50 and older? 
Do you live in the Rochester, NY area (including Buffalo, Syracuse, and surrounding areas)?

Be counted! 

Deaf Senior Services Coalition (DSSC) wants to COUNT you! 

DSSC wants to identify necessary services for Deaf, Hard of Hearing, DeafBlind, DeafDisabled, and Late-Deafened people who are 50 years and older in the Rochester area. DSSC has identified gaps in services, such as health care, home care, rehabilitative services, and long term care.  

We need to COUNT how many deaf/hard of hearing/deafblind/deafdisabled/late-deafened people who live in the Rochester, NY area in order to improve services.

Your participation is voluntary.  By filling out the form below, you are allowing DSSC to gather demographic information and COUNT you. 

DSSC is counting how many Deaf, Hard of Hearing, DeafBlind, DeafDisabled, Late-Deafened people live within an hour of the Rochester, New York area. This is part of a national effort lead by United Hands Organization to count everyone in New York.

By sharing your email address, you give permission to DSSC and United Hands Organization to count you and contact you with any updates. 



Sign in to Google to save your progress. Learn more
Your First Name and Last Name:
What is Your Home Address? 
What city do you live in? 
What is Your Zip Code: *
Are you:  *
Required
How old are you:
Clear selection
What is your current living situation: 
Clear selection
How Do You Communicate? 
Your Email: 
(Your email WILL NOT be shared outside of DSSC and United Hands. We will only use your email to contact you with information about health care.)
 *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms