Resources Application

Resources Application

Hearing aids, FM system, ASL lessons, Speech Therapy

  • Between the ages birth and 22 years old (while in high school)
  • Medically diagnosed with hearing loss
  • Must prove financial hardship as determined below:


Possible source of income:

  • Social Security and SSI
  • Public Assistance
  • VA Pension
  • Child Support
  • AFDC
  • Old-Age Pension
  • Disability
  • Alimony
  • Welfare
  • Work Pension
  • Interest from Stock, IRAs, 401(k)s
  • Black Lung Payments

Assets (include but not restricted to):

  • Savings
  • Checking
  • Money Market Accounts
  • Annuities
  • IRA/401(k)
  • Reverse Mortgage
  • CDs
  • Home Equity Loan
  • Stocks/Bonds
  • Burial Accounts
  • Property

In determining eligibility, Aid the Silent will consider funds from all sources of income.


GENERAL INFORMATION

Applicant’s Full Name:
Date of Birth:
Age:
Mailing Address:

Parent's Full Name:
Parent's Email:
Parent's Home Phone:
Parent's Cell Phone:
Ethnicity:
African American
Native American
Asian American
White (not of Hispanic origin)
Black (not of Hispanic origin)
Latino/Hispanic
Hawaiian/Pacific Islander
Other


Name of person other than applicant, completing this form:

First Name:
Last Name:
Relationship to applicant:
Email:

List other doctor’s offices, agencies, organizations you have requested to receive financial assistance from in the fields below. Include the following:

Name of office/agency/organization:

Name of contact person:

Email of contact person:

Phone number of contact person:

Have you made this request to your primary health insurance carrier?
YesNo
Were you denied coverage?
YesNo
If no, what is the percent you are responsible for?:

AUDIOLOGIST INFORMATION

Audiologist Name:
Audiologist Email:
Audiologist Phone:
Audiologist Practice Name:

Please indicate what you are applying for:

Hearing AidsFM SystemSpeech TherapyASL Lessons

NOTE: In most circumstances, Aid the Silent can only fund one resource at the time of application, if chosen. If additional services are needed, indicate so in the message field at the bottom of the application.

 


Amount requested:

Primary care physician/pediatrician

Doctor’s name:
Doctor’s email:
Doctor’s phone:
Doctor’s office/clinic:

Approved funds will be distributed directly to the service provider.


Do you currently wear hearing aids?

YesNo

If yes, indicate below:

Brand:
Model:
Date received:

Do you currently use an FM system?

YesNo
Do you own it?
YesNo

If yes, indicate below:

Brand:
Model:
Date received:

Are you participating in speech therapy?

YesNo
PrivateSchool System
How long have you received speech therapy?
How long were your sessions for speech therapy?

Are you participating in ASL lessons?

YesNo
PrivateSchool System
How long have you received lessons?
How long were your sessions for ASL lessons?

Applicant’s Name of school:
PublicPrivate

HOUSEHOLD AND FINANCIAL INFORMATION

# of Dependents:
Annual Household Income (NET):

List all household members

1. First Name:
Last Name:
Relation to applicant:
Date of birth:
2. First Name:
Last Name:
Relation to applicant:
Date of birth:
3. First Name:
Last Name:
Relation to applicant:
Date of birth:
4. First Name:
Last Name:
Relation to applicant:
Date of birth:
5. First Name:
Last Name:
Relation to applicant:
Date of birth:
6. First Name:
Last Name:
Relation to applicant:
Date of birth:
7. First Name:
Last Name:
Relation to applicant:
Date of birth:
8. First Name:
Last Name:
Relation to applicant:
Date of birth:
Additional members can be added in the comments section at the end of the application or attached in a separate document.
If selected, you will be asked to show proof of income.

List all sources of income: (salary, child support, alimony, social security, etc.)

Parent/Guardian:

A
Source of income:
Amount $ month:
B
Source of income:
Amount $ month:
C
Source of income:
Amount $ month:

Other Parent/Guardian:

A
Source of income:
Amount $ month:
B
Source of income:
Amount $ month:
C
Source of income:
Amount $ month:


All information must be provided to receive assistance

HOUSEHOLD INCOME
Amount per month
Net Employment:
Unemployment income:
Child Support:
Social Security:
Food Stamps:
Savings:
Housing Assistance:
Other income:

TOTAL INCOME:
HOUSEHOLD EXPENSE
Amount per month
Mortgage/rent/home insurance:
Electricity:
Gas:
Water/Sewer:
Phone (home/cell/internet):
Cable (TV subscriptions):
Health/medical bills & prescriptions:
Car payment/insurance:
Childcare:
Average food expense:
Other expenses:

TOTAL EXPENSES:

Do you currently have:

Checking: YesNo
(if yes, provide a copy of the last 6 months of current bank statements.

Savings: YesNo
(if yes, provide a copy of the last 6 months of current bank statements.

CD(s): YesNo
(if yes, provide copy of most recent statement.)

Stocks/Bonds: YesNo
(if yes, provide copy of most recent statement.)

Do you own property: YesNo

IRA/401(k): YesNo
(if yes, provide copy of most recent statement.)

Money Market Account: YesNo
(if yes, provide copy of most recent statement.)

Burial Account: YesNo
(if yes, provide copy of most recent statement.)

Annuity: YesNo
(if yes, provide copy of most recent statement.)


Please attach all current income and expense documents and the first 10 pages of your most recent tax return. If you do not file taxes and receive government benefits, submit a copy of your award statement of these benefits.


Additional information:

Are you a Medicaid recipient:
YesNo

What is your current health insurance coverage?

Does your health insurance cover hearing aids?
Don’t knowYesNo

If yes, what benefit?

Group #:

Member ID # (applicant):

Name of policy holder:

Date of Birth of policy holder:
Don't know

HEARING INFORMATION

Please attach audiogram. For any sponsorship to be considered, audiogram must accompany application.


Age when hearing loss was diagnosed:

If applicable, age at which applicant was fitted with hearing aid(s):

If applicable, age at which applicant received cochlear implant(s):

If applicable, age at which ASL was taught:

What other method(s) of communication and educational support service(s) are used in daily communications and educational settings?
Check all that apply:

Lip Reading
Sign Language System(ASL, Signed English, Finger Spelling, etc.)
Cued Speech
Note Taker
Communication Access Real‐time Translation (CART)
Oral Interpreter(s)
Sign Language Interpreter(s)
Auditory Listening Device, such as FM System

Uses sign language with:

Teachers/professorsFriends who are deafFriends with typical hearingOther, please describe:


Why should you be selected to receive assistance?
Any additional information that should be considered?

Aid the Silent Program Participation Agreement
I understand that the information I submit to Aid the Silent concerning the applicant’s level of hearing loss, medical history, parent/guardian’s annual income, family size, family resources, insurance and all financial information is subject to verification by Aid the Silent. I understand that if I knowingly omit or submit false information, I will be denied consideration.

Applicant’s Full Name
Parent/Guardian Name

Authorization for Use and Disclosure of Information Waiver
I authorize Aid the Silent to use my child’s information and photo to help bring awareness to other families in need. Images and information will be used for the nonprofit’s marketing materials, which includes printed collateral, social media campaigns, radio stations, television, newspapers, newsletters, corpo-rate scrapbook/bulletin and other media.

Applicant’s Full Name
Parent/Guardian Name