Help us complete a national registry of people who are DeafBlind. All identifying information is kept confidential. This information is used as a census of persons who are DeafBlind or have combined hearing and vision loss. The census information supports development of programs, research and grants. Your written consent is required to add your name to the registry.
When you have completed the form below, please click the “SUBMIT” button. For assistance with this form email the office at HKNCInfo@helenkeller.org.
Contact your regional representative if you relocate or change your phone number or email address.
English version form Word download
Spanish version PDF form download
Please complete the form and send to: HKNCInfo@helenkeller.org.