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* 1. Name of Child

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* 2. Child's Date of Birth

Date / Time

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* 3. Family Contact info

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* 4. Families Preferred method of contact

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* 5. Was your child identified as a result of the Alabama Newborn Screening Program?

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* 6. Please give a brief description of the child's hearing loss (is it bilateral, unilateral, the degree, etc.) and if your child has cochlear implants and/or hearing aid.

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* 7. Referring agency information

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* 8. Alabama Hands & Voices is a non-profit 501(c)(3) organization. Funding is provided by the Alabama Department of Public Health, the Alabama Department of Rehabilitation Services, chapter members of Alabama Hands & Voices and various individuals. Thank you for referring this family to be contacted by the Alabama Hands & Voices Guide By Your Side program. A Parent Guide will connect with the family soon. 

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