Parent Infant Playgroup REGISTRATION Form Parent Name * First Name Last Name Email Address * Phone/Text * (###) ### #### Preferred time of day to be contacted: Morning Mid-day Late afternoon County of Residence * Child First and Last Name * Child's Date of Birth * Please describe child's hearing loss: * Child's Hearing Technology: * Hearing Aid Cochlear Implant BAHA None Language used in home: * Comments: Thank you!
