National Registry

Overview

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 hkregistry@hknc.org.

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

Status *

New

Updated

First Name *

Middle Name

Last Name *

Maiden Name

Date of Birth *

mm/dd/yyyy

Gender

Male

Female

Mailing Address *

Mailing Address 2

City *

County

State / Territory * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip *

Email

Phone

Phone Type - Select -TelephoneText OnlyVideo PhoneTTY

Employed

Yes

No

Veteran

Yes

No

Job Title

Identify your vision condition *

Identify your hearing condition *

Syndrome / Other Conditions

I am interested in having my HKNC Regional Representative contact me about local and HKNC Services *

Yes

No

I want to subscribe to the free, quarterly CONNECT! email Newsletter

Yes

No

This form was completed by the person described above *

Yes

No

Relationship to individual *

First Name *

Last Name *

Agency

Mailing Address

Mailing Address 2

City

County

State / Territory - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip

Email

How May We Contact You? EmailMail (Normal Print)Mail (Large Print)Contracted BrailleUncontracted Braille

How do you want to receive the CONNECT! Newsletter

I have obtained permission to submit this information on behalf of the individual *

Yes

No

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

Last Name *

First Name *

Date *