Individual / Family Membership Form Individual and Family Membership Application please note the * is a required field Name* : Address*: City*: State*: Zip Code*: Email Address*: Phone Number*: Names and BIRTH YEARS of your Children. Name: DOB: Select: Deaf PlusDeaf / Hard of Hearing Name: DOB: Select: Deaf PlusDeaf / Hard of Hearing Name: DOB: Select: Deaf PlusDeaf / Hard of Hearing My Child does not have a hearing loss. My child does not have a hearing loss. Please Check all that Applies: 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 hearingI am an individual that is deaf or hard of hearing.I am a StudentI am a GBYS FamilyI am a Grandparent of a child that is deaf or hard of hearingI am the adoptive parent of a child that is deaf or hard of hearing. Type of Hearing Loss: UnilateralBilateralAuditory NeuropathyMondiniAquiductMicrobial / ArresiaConnecxin 26Deaf/BlindLarge VesicularConductive Degree of Hearing Loss: Right: MildModerateSevereProfound Left: MildModerateSevereProfound Child's Primary Communication Mode: Listening/ Spoken LanguageASLCued SpeechSigned Exact EnglishOther Asistive Devices Used: Hearing AidsBAHACochlear ImplantPersonal FM System Other Heath Condition or Diseases: I would love to volunteer to help the group in the following ways: Feel free to check as many as you are interested in. Event CommitteeNewsletterAdvocacyBill of RightsMediaMembership / Fundraising I have the following talent that I am willing to share: ( One you click on Submit, you will be directed to our payment system ) PLEASE NOTE: Using this system will automatically AUTO-Renew your membership every year on your anniversary date. To CANCEL your auto-renewal membership, please Call or Email to firstname.lastname@example.org. We will remove you from our Auto-Renewal system.