Network for Deaf/HOH & Blind/Visually Impaired Registration
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First name:

Last name:

Title (e.g., Mr., Mrs., Ms.):

Degree (if professional):

Street:
City:
State:
Zipcode:
Country:

Email:
Telephone:
Fax:

Name of individual:
Sex: Male Female
Birth year:
Current age:

Type of living arrangement (e.g., home, group home):

Your relationship to individuals (if relative or professional, please explain:

If professional, area of expertise/training:

Does the individual have a developmental disability? Yes No
    If 'yes,' please check which one(s):
    Autism
    Asperger syndrome
    PDD
    Other -
    Please explain:
Disability:
Hearing impairment
Deaf
Visual impairment
Blind
Other -
Please explain:

Does he/she wear glasses? Yes No

Does he/she use a hearing aid? Yes No

Does he/she have seizures? Yes No In the past, but not currently

Can we share your contact information with other parents/caregivers? Yes No

Can we share your contact information with professionals? Yes No

Do you have suggestions on ways we can help you? If so, please send an email to us at: HearingAndVisuallyImpaired@ autism.com