Resources Application

Resources Application

Hearing aids, FM system, ASL lessons, Speech Therapy

  • Eligibility requirements
  • Applicants reapplying for assistance cannot do so within 5 years of awarded resources.
  • Between the ages of 2 and 18 years old
  • Medically diagnosed with bilateral hearing loss with moderate to profound loss
  • Maximum annual household income as determined below:


Number of Dependents Total Household Income
(NET)
 1  $22,980
 2  $31,020
 3  $39,060
 4  $47,100
 5  $55,140
 6  $63,180
 7  $71,220
 8  $79,220
 Each additional person $4,060

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:

INSURANCE INFORMATION


Insurance:
Primary card holder:
Policy number:
Group number:


Additional information regarding insurance:


AUDIOLOGIST INFORMATION

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

Please indicate what you are applying for:

Hearing AidsFM SystemSpeech TherapyASL LessonsCamp
(IF APPLYING FOR CAMP, PLEASE FILL OUT CAMP APPLICATION INSTEAD)

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:

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):

* 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:

Please attach audiogram:

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

Please attach other documents: (tax return, bank statements, etc)