REGISTRATION - Discover CVI

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
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