Discover CVI
For families interested to join a CVI Parent Group
Child's Name
First Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
Child has
Cortical Visual Impairment (CVI) only, NO hearing loss
CVI and hearing loss
Brief description of child's hearing impairment
School/District
Number of family members participating
Parent's Name 1
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State
Zip Code
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Parent's Name 2
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State
Zip Code
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Accommodations
Why do you want to join Discover CVI: Parent Support Group?
What are your expectations from this group?
How can Discover CVI: Parent Support Group help you and your child with CVI?
Are you interested to help organize an event?
Yes
No
Submit
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