Please choose one:

I wish to be immediately matched with another family.
I wish to allow other families looking for a match to contact me.
Both; I would like an immediate match AND I would like future families to contact me.

_________________________________________________

Family Information

Name:

Address:

City, State, Zip:

County:

Please choose the best way to reach you:

Daytime phone
Alternate phone
Email

_________________________________________________

Child Information

Clild's Date of Birth:

Hearing Loss:
Unilateral (One Ear)
Bilateral (Both Ears)

Degree of Hearing Loss:
Mild
Moderate
Severe
Profound

Type of Hearing Loss:
Permanent Conductive (Middle Ear)
Sensorineural (Inner Ear or Nerve Loss)
Auditory Neuropathy/Dysynchrony Disorder

Technology Used:
Hearing Aid
Cochlear Implant
Implantable Hearing Aids (i.e. Baja)

Communication Approach:
Bilingual / Bicultural (ASL)
Auditory / Oral
Total Communication
Other

Please pick one of the following if you are looking for an immediate match.
I would like to be matched with another family by:

Location
Degree of Loss
Technology Used
Communication Approach
Child’s Age
Other

Please share any thing else that you would like for Hands & Voices to know and share about your child and/or family (i.e. other health, developmental, or physical conditions, special interests, etc.):

If you would like for Hands & Voices to keep your information in the Parent Match database so that we can connect a future family to you, please write a short introduction describing you and your family in the box below.  This information will be shared with families who are requesting to be matched with someone just like you!!  Please feel free to share things that make your child and family special, your reasons for participating in the Hands & Voices Parent Match initiative, and anything else that you would like them to know.

By returning this form you give Wisconsin Families for Hands & Voices permission to release this information to other families for the sole purpose of parent matching.

  - Click this button to register your info with us.

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