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If you’d like to learn more and/or sign up for your child to participate, please complete this brief entry survey!

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Parent Name *

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Last

Child Name *

First

Last

Email *

Phone Number

Child's Birthdate (Month, Year) *

Has your child been diagnosed with hearing loss? *

• Yes
• No

Has your child ever received speech-language therapy/services? *

• Yes
• No

How did you hear about us? *

• My child’s school/clinic
• Friend/family
• Instagram post
• Facebook group
• Other social media post
• Other

If you found us on Instagram, please include your handle here and we will reach out to you!

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