Hearing Improvement Kids Equipment Fund (H.I.K.E)
If your child needs hearing aids and they are not covered by insurance, fill out this application to see if you qualify for assistance.
Name of Child
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Name of Parent or Guardian
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Previous Award?
*
Yes
No
If yes, when?
-
Month
-
Day
Year
Date
Referring Physician and/or Audiologist
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of last ENT visit:
*
-
Month
-
Day
Year
Date
Please describe the nature of your request:
*
Equipment needed:
*
Please verify that you are human
*
Submit
Should be Empty: