Listen to Me!® Conferences

Language Preference / Preferencia de idioma
Please select your preferred language for completing this application. Por favor seleccione el idioma en el que prefiere completar esta solicitud.*

English / InglésEspañol / Spanish

We don’t have any California conferences scheduled at the moment! Please leave your email, and we will notify you when new conferences are scheduled.
example@example.com
We don’t have any Hawaii conferences scheduled at the moment! Please leave your email, and we will notify you when new conferences are scheduled.
example@example.com
Listen to Me!® — New Families Upcoming
Listen to Me!® — Reunion Upcoming
Child
Child Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Parents
Parent 1 Name*

First NameLast Name
Parent 2 Name

First NameLast Name
Nanny/Other Caregiver

First NameLast Name
Email*
example@example.com
Mobile Number*

Area CodeNumber
Addresses
Postal Address
P.O. Box*
If you don’t have the information, type N/A.
Postal Code*
If you don’t have the information, type N/A.
County*
Physical Address
County*
Town*
Conference Attendees
Who will attend the conference? (Select all that apply)*

Parent 1Parent 2BothOther primary caregivers
Do you have other children who will participate in the sibling group?*

YesNoMaybe
Siblings attending (click “Add another sibling” if there are more)*
Hearing loss history & current audiology/medical care
Date of hearing loss diagnosis*

MonthDayYear
Date
Cause of child hearing loss*
Where does your child receive audiology/medical services for his/her hearing aid/cochlear implant?
Clinic name*
Clinic city *
County*
Please describe your child's hearing
Right Ear
Right ear hearing loss*

NormalMildModerateSevereProfound
Right ear type of loss*

SensorineuralConductiveMixedNot applicable/unsure
Right ear device*

Hearing AidMed-El Cochlear ImplantNo device
Left Ear
Left ear hearing loss*

NormalMildModerateSevereProfound
Left ear type of loss*

SensorineuralConductiveMixedNot applicable/unsure
Left ear device*

Hearing AidMed-El Cochlear ImplantNo device
I want my child to communicate using...*

Listening & Spoken Languages OnlySign Language OnlySign Language & Spoken Language
Service providers working with you and your child
Audiologist
Audiologist Name*

First NameLast Name
Audiologist institution *
Audiologist email *
example@example.com
Mobile Number*

Area CodeNumber
Teacher of the Deaf
Professional name

First NameLast Name
Teacher of the deaf professional center
Teacher of the deaf professional email
example@example.com
Teacher of the deaf professional phone number

Area CodeNumber
Teacher of the deaf professional minutes per week
Teacher of the deaf professional service method

Listening & Spoken LanguageSign + SpeechSign Language
Speech-language pathologist
Speech-language pathologist name *

First NameLast Name
Speech-language pathologist center*
Speech-language pathologist email*
example@example.com
Speech-language pathologist minutes per week *
Speech-language pathologist service method*

Listening & Spoken LanguageSign + SpeechSign Language
Other Professional
Other professional name

First NameLast Name
Other professional center
Other professional email
example@example.com
Other professional phone number

Area CodeNumber
Other professional minutes per week
Other professional service method

Listening & Spoken LanguageSign + SpeechSign Language
ALLERGY INFORMATION
Select person(s) in family with allergies we should be aware of: (select as many as needed)*

ChildParent 1Parent 2Sibling 1Sibling 2Sibling 3N/AOther
Attendee name & allergy*
EMERGENCY CONTACT
Emergency contact: *

First NameLast Name
Emergency Number*

Area CodeNumber
AUTHORIZATION FOR RELEASE OF INFORMATION
I, the undersigned, authorize the following institutions (check all that apply)*

Cochlear Implant CenterAudiologistChild SchoolOther service providers
and their employees to disclose/release the following information from my child’s records

Audiological RecordsEducation RecordsSurgical/ Operative RecordsSpeech Language Evaluation NotesOccupational TherapyMedical RecordsOther
to: The Listen to Me! Conference and its employees.
I also authorize the Listen to Me! Conference to contact me at the above phone number and addresses with correspondence that specifically relates to the Listen to Me! Conference.

This authorization shall expire no later than exactly one year after I submit this application or upon termination of my child’s enrollment in the Listen to Me! Conference (whichever is sooner). I understand that I may revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing. I understand that the revocation will not apply to information that has already been released in response to this authorization. By signing below I represent and warrant that I have authority to sign this document and authorize the use or disclosure of protected health information and that there are no claims or orders pending or in effect that would prohibit, limit, or otherwise restrict my ability to authorize the use or disclosure of this protected health information.
If You are a Provider and Filling This Application on Behalf of the Family, Please TYPE YOUR NAME

First NameLast Name
Parent/Provider Signature*
Type your legal name to sign this form electronically.
The cost for attending Listen to Me is 5,000 Shillings per family.

To complete the registration, please submit 5,000 Shillings.

Submit payment to:

Hearing Implants Limited:

Lipa na Mpesa

Paybill 600100

Account-0100004702907

Please note, your application will not be confirmed until payment has been submitted.

THANK YOU
The cost for attending Listen to Me is 2,500 Shillings per family.

To complete the registration, please submit 2,500 Shillings.

Submit payment to:

Hearing Implants Limited:

Lipa na Mpesa

Paybill 600100

Account-0100004702907

Please note, your application will not be confirmed until payment has been submitted.

THANK YOU
Send me a copy of my responses
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Language Preference / Preferencia de idioma

Listen to Me!® — New Families Upcoming

Listen to Me!® — Reunion Upcoming

Child

Parents

Addresses

Postal Address

Physical Address

Conference Attendees

Hearing loss history & current audiology/medical care

Where does your child receive audiology/medical services for his/her hearing aid/cochlear implant?

Please describe your child's hearing

Right Ear

Left Ear

Service providers working with you and your child

Audiologist

Teacher of the Deaf

Speech-language pathologist

Other Professional

ALLERGY INFORMATION

EMERGENCY CONTACT

AUTHORIZATION FOR RELEASE OF INFORMATION

to: The Listen to Me! Conference and its employees.