Request for Deaf/HH Partner and/or Parent Partner
Thank you for your interest in our Deaf/HH and Parent Partners  Please fill out the following request form for EHDI to reach out to you regarding matching you with one of our Partners. 
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Your name *
Your deaf/hh child's name *
Age of your child who is deaf/hh *
Email address *
Phone number *
Address *
Please give us a little bit of information regarding your child's hearing to help us match you better with one of our partners.
 - Type and degree of hearing loss, communication modes interested in, amplification technology interested in pursuing or currently using, any vision concerns or other medical or developmental concerns.
(ex. Bilateral moderate-severe hearing loss, using hearing aids, interested in learning ASL, etc.)
 *
Please list any specific requests you are looking for in a Partner.
(Ex. For a Parent Partner I want someone whose child has the same type of hearing loss as mine or wears Cochlear Implants. For a Deaf/HH Partner I would like to be matched with someone who can help us learn ASL, or I would like to be matched with a Hard of Hearing adult , etc.)
 *
EHDI serves children 0-3 with any degree of hearing loss and we are able to provide Deaf/HH Partners and/or Parent Partners to match them with. Please let us know which type of partner you would like. (you can choose both if you wish!) *
Required
Thank you! Our EHDI staff will be in touch soon!
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