D/HH Playgroup Registration

NH’s Deaf/Hard of Hearing Role Model Program invites families to join our playgroup to meet deaf and hard of hearing adults as well as other families who have children who are deaf, hard of hearing or deafblind!

Name*

First NameLast Name

Email Address: *

example@example.com

Child's Date of Birth*

Phone Number*

Please enter a valid phone number.

Are you interested in receiving information about our future programs?*

YesNot at this time

Preferred Communication Method

EmailPhone (Voice)Phone (Text)Phone (VP)

Register for:*

Oct. 19th, 10-11:30am at Rollins Park in Concord NH

How did you hear about this event?

Service providerSocial mediaNDHHS websiteOther

What questions do you have for our role models/family coordinator?

Any additional comments/questions:

Interpreter or other accommodation requests:

Do you or your child have any food or other allergies we should know about?

Do we have your permission to take pictures of you and/or your child during the event?*

Yes and I have read and signed the agreement below.No

I hereby grant Northeast Deaf and Hard of Hearing Services, Inc. permission to use my likeness in a photograph or other digital reproduction in any and all of its publications, including the center’s website entries, project brochures, presentations and displays without payment or any other consideration.

I understand and agree that these materials will become the property of Northeast Deaf and Hard of Hearing Services, Inc. and will not be returned. I hereby irrevocably authorize Northeast Deaf and Hard of Hearing Services, Inc. to copy, exhibit, publish or distribute this photo for purposes of publicizing its programs or for any other lawful purpose.

In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph. I hereby hold harmless and release and forever discharge Northeast Deaf and Hard of Hearing Services, Inc. from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

I am 18 years of age and am competent to contract in my own name. I have read this release before signing below and I fully understand the contents, meaning, and impact of this release.

I hereby certify that I am the parent or guardian of First Name Last Name and do hereby give my consent without reservation to the foregoing on behalf of this person(s).

Signature

Do we have your permission to communicate with NH's Early Hearing Detection & Intervention Program based at the NH Dept of Health and Human Services regarding your family's participation in our Program?*

Yes and I have signed below to indicate my consent.No

Signature