LEAP Mini-Mixer and LOFT Q&A

LEAP Mini-Mixer and LOFT Q&A

Friday, October 18, 2024 @ 7-8:00pm ET
We are excited to invite you to AG Bell's LEAP Mini-Mixer and LOFT Q&A!

*This event is for High School students with hearing loss only*
- Connect with High School students with hearing loss from all over the world
- Learn about LOFT (Leadership Opportunities for Teens) from LOFT Alum
- Make new friends!
Once you have registered and we have received Parent permission (if under 18 years of age), we will send you the Zoom information through email and calendar invite from Youth Programs Coordinator, fmatlock@agbell.org. If you are 18 or older, please complete the photo/video release form at the bottom of this form.

We look forward to seeing you there!
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Age*
Age when hearing loss was diagnosed?*
Type of hearing loss:*

SensorineuralConductiveMixed
My hearing loss is:*

BilateralUnilateral in left earUnilateral in right ear

Indicate the amplification device (s) you use:*

	Left Ear	Right Ear
Hearing Aid (s):
BAHA (s):
Cochlear Implant (s):

The LEAP Mini-Mixer and LOFT Q&A's audience is high schoolers between the ages of 14-18 years old. AG Bell asks that teens who are under the age of 18 seek permission from their parent/guardian to attend. LEAP Facilitators (Young Adults with hearing loss/LOFT Alumni) and AG Bell staff will facilitate and be present throughout the evening.
I am under the age of 18 and have received parental consent to attend this event.

Check Box to Confirm
If you are under 18, please provide the name and email of your parent/guardian.

This information is required so that AG Bell may follow up with your parent/guardian if needed to obtain future consent for photo/video release.
Parent/Guardian Name

First NameLast Name
Parent/Guardian Email
example@example.com
Photo and Video Release (please complete if over 18 years old)

AG Bell's likes to take group photos at the LEAP Mini-Mixer and LOFT Q&A. Photos are shared with the group after the event is over as well as shared through AG Bell's social media channels and website for promotion of youth programs for the upcoming year.
I hereby grant permission to the Alexander Graham Bell Association for the Deaf and Hard of Hearing (AG Bell) to use the photograph(s) and video(s) of {applicant} for unlimited use in any AG Bell publications, periodicals, brochures, displays, booklets, website and in any of AG Bell’s public relations or fundraising activities. I give and grant to AG Bell and its designees, licensees, successors and assigns, the right to use, publish and copyright, my child’s name, voice, likeness, actions and biographical data, in whole or in part. I hereby waive any right that my child or I may have to inspect or approve the media, any materials that may be used in connection with the media, or the use to which it may be applied.
Signature for Photo/Video Release (if 18 years and older)

Clear
Should be Empty:

LEAP Mini-Mixer and LOFT Q&A

If you are under 18, please provide the name and email of your parent/guardian.

Photo and Video Release (please complete if over 18 years old)