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Speechreading/Lip Reading Application

Application form

Lip Reading 101

REGISTRATION FORM

(Please Print)
Today’s date: Member of HLAA:Yes ____No _____

APPLICANT INFORMATION

Applicant’s last name:               
First:                                       Middle:   
Mr.      Mrs.                                        
Miss   Ms  




Marital Status:  ___Single ___Mar ___Div ___Sep ___Wid






Over 18?    Yes  ____           No  _____
Email: 
                             



Street address: Apt. # Home phone no.:
()
P.O. box: City: State:                           Zip Code:  

Occupation:

( )


 

 


 


Hearing INFORMATION

Hard of Hearing since: Do You Wear Hearing Aid(s):  ___Yes  ___No


Do You Sign:    Yes___No___ Cochlear Implant(s)   ___Yes   ___No
Do you use captioning:____Yes____No Is your hearing loss:  

_____Mild______Moderate____Severe____
Profound____Totally Deaf____Don’tKnow



My ENT Dr. is:



My Audiologist is:



Do you have your own transportation:  Yes  No
Comments: Cost:$35 Members  $45 Nonmembers
Mail to:Treasure Coast Chapter, HLAA

%Cheryl Nolte

556 Paurotis Ln

Fort Pierce, FL34982

Lipreading Class email: speechreader1@gmail.com

Website:www.treasurehearing.org

Make checks payable to:
Treasure Coast Chapter, HLAA

No credit or debit cards accepted.



IN CASE OF EMERGENCY

Name of local friend or relative (not living at same address): Relationship to applicant: Home phone no.:

Work phone no.:




() ()
The above information is true to the best of my knowledge.
Applicant signature                                
Date

Treasure Coast Chapter/Hearing Loss Association of America

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