New Zealand Federation for Deaf Children (Inc.)

FAMILY INFORMATION CARD

Help us keep you informed

Child’s Full Name			Gender
Full Postal Address			Post Code
Level of Hearing Loss			Date of Birth
Ethnicity			Iwi affiliation (if applicable)
Parents/Caregivers Name
Phone			Fax
Email			Mob
Additional Remarks
Type of registration
Would you like to have contact with a Parent Mentor?
A Parent Mentor is a parent of a child with a hearing loss who has an understanding of some of the issues that may face your family.
Reload Image Enter the above code (case-sensitive). Information collected by the New Zealand Federation for Deaf Children Inc. will remain confidential. Data derived from this information may be used for accountability and funding purposes.