Print form and mail to:

Project for New Mexico Children & Youth Who Are Deafblind
Center for Development and Disability
2300 Menaul NE
Albuquerque, NM 87107

OR fax to: (505) 272-5280

Call (877) 614-4051 for more information.

Please fill in as much information as possible. This form is the first step in receiving direct, personalized services from the Project for NM Children & Youth Who Are Deafblind. We will also need additional information on individuals birth through 21 for the Deafblind Census. 

Part I: Information on Individual with Dual Sensory Impairment:
  

Name:
Address:
City, State, ZIP:
Date of Birth:	Male		Female

  

Ethnic Background:

White  Black Spanish/Hispanic Mexican, Mexican-American, Chicano

Indian (American)Tribe: Asian/Pacific Islander Mixed Asian/Pacific Islander Unknown Other

Parent/Guardian Name:

  

Parent/Guardian Address (if different than above):

  

Home Phone:

Work Phone:

 

Name of Program/School:

Teacher(s):

  

School Address:

 

City, State, ZIP:

 

School Phone:

PART II: Referred by:

Parent/Guardian named above:

Other:

Please Specify:

Please provide contact information if NOT Parent/Guardian:

Name:

Address:

City, State, ZIP:

  

Agency:

Phone:

 

Email:

Part III: Services and Information Requested:

Please contact me (person making referral).
Please contact the individual/family.
Please contact the school.
Please send me a brochure.
Other: Request/Comments/Notes: