In Partnership with Sound Beginnings,
”Meet the Author Free Family Book Event” with Dr. Jasmine
at HEAR Wisconsin’s Annual Fall Fest
Saturday, OCTOBER 4

(REGISTRATION CLOSES 9/25/25)

10:30 AM Sign in
11:00 - 11:30 AM Talk and Book Reading
11:30 - 12:00 PM Book Signing and Photo Opportunity

If you have a child (age 0-3) with a permanent hearing loss you can receive a
FREE book by the author. Families must complete a developmental screening prior to receiving their book. 1 per family

Parent's (Guardian) First & Last Name

First Name

Last Name

Phone Number

(###)

###

####

Email Address

Please tell us how many adults and children will be attending.

Number of Adults

Number of Children 0-3 years old

Number of Children 4+ years old

Child's With Permanent Hearing Loss

First Name

Last Name

Child's Date of Birth

Additional Child With Hearing Loss

First Name

Last Name

Child's Date of Birth

What County do you live in?

Primary Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Tell us about your child's hearing loss

Do they use hearing technology?

Is your child currently receiving any early intervention services or have they received services in the past?

Yes

No

If yes, where are they currently / did they receive services?

What language(s) are used in the home?

Do you need an interpreter?

Yes

No

If yes, what language?

ASL

Spanish

Other

Do you have any questions or comments?

In Partnership with Sound Beginnings, ”Meet the Author Free Family Book Event” with Dr. Jasmine at HEAR Wisconsin’s Annual Fall Fest Saturday, OCTOBER 4

(REGISTRATION CLOSES 9/25/25)

In Partnership with Sound Beginnings,
”Meet the Author Free Family Book Event” with Dr. Jasmine
at HEAR Wisconsin’s Annual Fall Fest
Saturday, OCTOBER 4