National Registry


The purpose of the HKNC National Registry of Persons Who are DeafBlind is to provide basic information about people with combined vision and hearing loss in the United States. This information is to be used as a census of persons who are DeafBlind, as a planning tool and for research purposes.  All identifying information is confidential. Written consent from the individual or guardian is required before a person becomes registered by the Helen Keller National Center.

When you have completed the form below, please click the "SUBMIT" button below. For assistance with this form email the office at

Contact your regional representative if you relocate or change your phone number or email address.

To download the English or Spanish version of this form, click here.

National Registry Form

Information about individual who is DeafBlind

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By digitally signing, I allow HKNC to use the information in this form for statistics on deaf-blind individuals