Tennessee Hands & Voices

P.O. Box 122

Trenton, TN 38382
Email:
membership@tnhandsandvoices.org

Membership Form

NAME:___________________________________________________________________________
ADDRESS:_________________________________________________________________________
EMAIL:_____________________________________________ PHONE NUMBER________________
NAMES and BIRTH YEARS of your CHILDREN
NAME
DOB
D/HOH
Deaf Plus
_______________________________________________
__________________

_______________________________________________
__________________

_______________________________________________
__________________

Please check all that apply

I am the parent of a child that is deaf or hard of hearing
I am a professional who works with the deaf or hard of hearing - Job
Title________________________________
Ion
would
lovechild
to volunteer
Information
deaf/hh
or adult to help the group in the
I am an individual that is deaf or hard
of hearing
ways:of a child that is
Type of HL
I am a student
I am thefollowing
grandparent
free to check Auditory
as many as you are interested in.
UnilateralFeel Bilateral
deaf or hard of hearing
Event Committee
Advocacy
Neuropathy
I am a GBYS family
I am the adoptive parent of a child that
Newsletter
Media
Mondini
Aquiduct
is deaf or hard of hearing
Bill of Rights

Microtial/Atresia
Membership/fundraising
Connexin
26 Deaf/Blind Large
I
have
the following talents that I am willing to
Vestibular
share:______________
Conductive
Degree of HL
Prices:
$25.00 Family
Right EarMembershipLeft
Ear
available upon request )
Mild (scholarships are
Mild
Moderate
Moderate
$40Professionals
$45 Small
Severe
Severe
Businesses Profound
Profound
I would
like to apply
Childs Primary
Communication
Mode for a scholarship
For Membership Personnel Only
Listening/Spoken Language
ASL
New membership Pkg mailed______________ Zoho
Signed Exact English
Membership Card
Membershiphvexcel
Cued Speech
Email added
Other
Renewal Date__________________
Assistive Devices Used
Hearing Aids
Cochlear Implant