Family Network Group registration form
We provide information and support to families with deaf and hard of hearing children in Western Australia. By registering, you will recieve information about opportunities to connect with other children and families on a similar journeyand activities for your child and family to attend.
Our Family Engagement Worker will contact you directly to see how we can support your family. All information provided will be kept private and confidential.
Parent/Carer/Guardian Name
*
First Name
Last Name
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Would you like our Family Engagement Officer from WA Foundation for Deaf Children to give you a call / text about any concerns you might have?
How would you like to be contacted?
Please Select
email
phone call
SMS
What is your first language?
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Details of Deaf or Hard of Hearing child 1
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Is your child?
Deaf or Hard of Hearing
Unilateral
Does your child use assisted hearing devices?
hearing aids
cochlear implant
BAHA
unaided/ N/A
Any other disabilities to be noted?
Details of Deaf or Hard of Hearing child 2
First Name
Last Name
Child's Date of Birth
-
Month
-
Day
Year
Date
Is your child?
Deaf or Hard of Hearing
Unilateral
Does your child use assisted hearing devices?
hearing aids
cochlear implant
BAHA
unaided/ N/A
Any other siblings? (please provide name and date of birth)
Where did you hear about the WA Foundation for Deaf Children?
community@wafdc.org.au
www.wafdc.org.au Level 2/200 Adelaide Terrace, Perth WA T(08)6266 6969
Submit
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