Mini - Hear in the Fox Cities

This mini-application is for financial assistance up to $400 for audiology services for a child up to age 21 in the Northeastern and Northcentral Wisconsin area.

*Ear Molds

*Dehumindifiers or Dryers

*Hearing aid batteries

*Hearing aid lost / repair

*Hearing Exam

This is not an all inclusive list, and is subject to modifications. If your request is for something other than above, please let us know in the application below.

Applications will be reviewed by the board in a timely manner and the applicant contacted with a decision. If necessary, Hear in the Fox Cities will contact the audiologist for a quote or they can email us at hear@hearinthefoxcities.org with the quote.

Hear in the Fox Cities will provide funding for minor expenses as long as the funds are available. We reserve the right to change eligibility at any time without written notification.
TO BE COMPLETED BY THE PARENT/GUARDIAN
Patient Name*
Name
Patient Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County you live in (Brown, Calumet, Outagamie, Winnebago, Waupaca etc)*
Your name*
Relationship to patient*
Your Email*
Your Phone #*
Format: (000) 000-0000.
I need help with
Tell us how we can help you. If you need to provide additional information, please email us at hear@hearinthefoxcities.org*
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Please upload the receipt or invoice paid and we will reimburse you. Or if you have a quote from the provider, we can pay the provider directly. If uploading a receipt, it must be dated 60 days or less to be reimbursed.

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By signing below, due to current financial challenges, I am in need of this assistance and would be truly grateful for your support.

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TO BE COMPLETED BY THE PARENT/GUARDIAN