En Voz Alta is pleased to be able to help the community of children

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En Voz Alta is pleased to be able to help the community of children
En Voz Alta is pleased to be able to help the community of children with
hearing loss in El Paso by providing hearing aids to those in need. En Voz
Alta, upon fund availability, will donate hearing aids annually, to children who
have the attached application completed and meet the eligibility requirements.
Children who are eligible to receive a donated hearing aid are as follows:
--have a hearing loss diagnosed by an Audiologist
--have documentation from Audiologist indicating need for a
hearing aid.
--have no insurance or limited coverage
--have no other resources
--a resident of Region 19 or Gadsden I.S.D. area
Families who are applying for assistance must provide the following:
--completed Application for Assistance
--copy of utility bill, showing proof of residency, dated within 1
month of date of application
--copy of front and back sides of insurance card
--completed AI/Deaf Ed teacher/SLP information form
(sent in by staff separately)
--copy of audiogram/audiological report completed within this past
year (provided by Audiologist)
Application deadlines are as follows: March 1, 2014; June 1, 2014; October 1,
2014; January 1, 2015. Applications may be submitted any time before the
above mentioned deadlines.
Please note that En Voz Alta will not cover the cost of cochlear implants,
BAHA implants or speech processors and/or parts.
For additional information, please contact Andrea Sweetnam at
(915) 478-0184 or Angie Lopez at 915-276-5764.
Thank you,
En Voz Alta
En Voz Alta
Application for Assistance: Hearing Aids
TO BE COMPLETED BY PARENT(S):
I, _______________ (parent), give consent to En Voz Alta to share the
following information on my child, ___________________, with the
Technology Assistance Committee in order for En Voz Alta to determine
candidacy for assistance. Date: ___________________
I, ______________ (parent), give consent to all personnel responsible for
completing this application, to release/provide information on my child,
______________, to En Voz Alta and the Technology Assistance Committee.
Date: ____________________
TO BE COMPLETED BY PARENT(S):
Child’s Name: _________________________________Age:_________________
Date of Birth: _________________________________
Parent(s) Name(s): __________________________________________________
Address: __________________________________________________________
__________________________________________________________________
Telephone Number: ____________________________
Insurance Information: _______________________________________________
__________________________________________________________________
AI/Deaf Ed Teacher: _________________________________________________
Speech Therapist: ___________________________________________________
Name of School (if attending): _________________________________________
Please indicate below why you are seeking assistance:
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
The information provided will be kept confidential. Please fax this along with
the other required documents of the application (see cover letter) to Mary
Ceglio at 915-242-8397 or mail to Mary Ceglio, c/o Christina Aragon, En Voz
Alta, University Medical Center Foundation, 1400 Hardaway, Suite 220, El
Paso, Texas 79903.
NOTE: The form completed by the AI/Deaf Ed Teacher/Speech Therapist
will be faxed by the staff to Mary Ceglio separately.
En Voz Alta
Application for Assistance: Hearing Aids
TO BE COMPLETED BY AI/DEAF ED TEACHER AND/OR
SPEECH THERAPIST
Please complete this section if the child has never worn hearing aids before and
parent is asking for assistance with the provision of hearing aid(s):
Child’s Name: _________________________________Age:_________________
Date of Birth: _________________________________
1. Has the child/family committed to wear his/her hearing aid(s) all waking
hours? _______________________________________________________
2. Has the child/family committed to being diligent in maintaining hearing
aid(s), to include timely visits to the audiologist? ______________________
_____________________________________________________________
_____________________________________________________________
3. Has this child/family committed to regularly participating in
suggested/required therapy/home based/academic programs to support the
development of communication? __________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
4. Does this child/family demonstrate financial need? ____________________
_____________________________________________________________
5. Additional Comments:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
The information will be kept confidential. Please fax this to Mary Ceglio at
915-242-8397.
En Voz Alta
Application for Assistance: Hearing Aids
TO BE COMPLETED BY AI/DEAF ED TEACHER AND/OR
SPEECH THERAPIST
Please complete this section if the child has worn hearing aids before and parent
is asking for a replacement/repair:
Child’s Name: _________________________________Age:_________________
Date of Birth: _________________________________
1. Does this child wear his/her hearing aid(s) all waking hours? ___________
If no, does this child’s family make every effort in increasing the amount of
time the child wears his/her hearing aid(s)? __________________________
_____________________________________________________________
2. Does this child/family demonstrate due diligence in maintaining hearing
aid(s), to include timely visits to the audiologist? _____________________
_____________________________________________________________
_____________________________________________________________
3. Does this child/family regularly participate in suggested/required
therapy/home based/academic programs to support the development of
communication? _______________________________________________
_____________________________________________________________
4. Does this child/family demonstrate financial need? ____________________
_____________________________________________________________
5. Additional Comments:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
The information will be kept confidential. Please fax this to Mary Ceglio at
915-242-8397.
En Voz Alta esta contento de poder ayudar a los ninos con perdida auditiva de la
comunidad de El Paso, con proveer audifonos a los necesitados. En Voz Alta,
dependiendo de la disponibilidad de fondos, donara audifonos anualmente, a los
ninos que tengan la aplicacion completa y que cumplan los requisitos.
Los ninos que son elegibles para recibir un audifono donado deben:
--tener una perdida auditiva diagnosticada por un Audiologo
--tener documentacion del Audiologo indicando la necesidad del audifono
--no tener aseguranza o que tener cobertura limitada
--residente del Region 19 o Distrito Escolar Independiente de Gadsden
Las familias que aplican para asistencia deben proveer lo siguiente:
--llenar la Aplicacion de Asistencia
--una copia de factura (gas, agua, luz) con domicilio actual, no mas de un mes
--hacer una copia de los dos lados de la tarjeta de aseguranza (si tienen)
--tener la forma de informacion llenada por el Maestro de Educacion para ninos
con perdida auditiva o por el Terapista del Habla. (ellos mandaran esta hoja por
separado)
--tener una copia del reporte audiologico mas reciente (el Audiologo lo provera)
Fecha limite de la solicitud: 1 de marzo del 2014, 1 de junio del 2014, 1 de octubre
del 2014, 1 de enero del 2015. Puede someter la solicitud antes de cualquier fecha
limitada.
Por favor tome nota que En Voz Alta no cubre el costo de los implantes cocleares,
implantes BAHA o procesadores del habla y/o partes.
Para mas informacion, por favor comuníquese con:
Andrea Sweetnam al 915-478-0184 o Angie Lopez al 915-276-5764.
Gracias,
En Voz Alta
En Voz Alta
Solicitud para Asistencia: Audifonos
PARA SER COMPLETADO POR LOS PADRES:
Yo,___________________(padre/madre),doy consentimiento a En Voz Alta de
compartir la siguiente informacion de mi hijo/a_______________________, con el
Comite de Ayuda Tecnologica para que En Voz Alta determine candidatura
para la ayuda. Fecha:_______________________
Yo,____________________(padre/madre),doy consentimiento a todo el personal
responsable por llenar esta aplicacion a proveer/relevar informacion sobre mi
hijo/a________________________, a En Voz Alta y al Comite de Ayuda Tecnologica.
Fecha:______________________
PARA SER COMPLETADO POR LOS PADRES:
Nombre del nino/a:_____________________________________Edad:___________
Fecha de Nacimiento:____________________________________
Nombre del Padre/Madre:_______________________________________________
Direccion:_____________________________________________________________________________
Numero de Telefono:_______________________________________________
Informacion de Aseguranza:_______________________________________________________
________________________________________________________________________________________
Maestro de Ninos con Perdida Auditiva:__________________________________________
Terapista del Habla:__________________________________________________________________
Nombre de la Escuela(si asisten):___________________________________________________
Por favor indiquen abajo porque buscan ayuda:__________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
La informacion que provee sera confidencial. Por favor mande por fax
esto junto con los otros documentos requeridos de la aplicacion(vea la
primera hoja) a Mary Ceglio al 915-242-8397. Tambien lo puede mandar
por correo a Mary Ceglio, c/o Christina Aragon, En Voz Alta, University
Medical Center Foundation,1400 Hardaway, Suite 220, El Paso,Texas
79903.
NOTA: La forma llenada por el Maestro de Ninos con Perdida
Auditiva/Terapista del Habla sera enviado por fax a Mary Ceglio por
separado.
Solicitud para Asistencia: Audifonos
PARA SER COMPLETADO POR EL MAESTRO DE NINOS CON PERDIDA
AUDITIVA O TERAPISTA DEL HABLA
Por favor llene esta seccion si el nino nunca ha usado audifonos antes y los
padres estan pidiendo asistencia con la provision de audifono(s):
Nombre del nino/a:_____________________________________Edad:___________
Fecha de Nacimiento:____________________________________
1. El nino/la familia estan comprometidos a usar su(s) audifono(s) todos los
dias mientras este despierto?_____________________________________________________
2. El nino/la familia estan comprometidos a darle(s) mantenimiento al/los
audifono(s), incluyendo visitas al audiologo?___________________________________
______________________________________________________________________________________
3. El nino/la familia estan comprometidos a participar regularmente en
terapias sugeridas o requeridas. Tambien, en programas academicos o algunos
en casa para apoyar el desarollo de comunicacion?___________________
______________________________________________________________________________________
______________________________________________________________________________________
4.Este nino/familia demuestra necesidad economica?_________________________
______________________________________________________________________________________
5. Comentarios Adicionales: __________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Esta informacion se mantendra cofidencial. Por favor mande esto por fax
a Mary Ceglio al 915-242-8397.
En Voz Alta
Solicitud para Asistencia: Audifonos
PARA SER COMPLETADO POR EL MAESTRO DE NINOS CON PERDIDA
AUDITIVA O TERAPISTA DEL HABLA
Por favor llene esta seccion si el nino ha usado audifonos y los padres piden
un reemplazo o reparacion:
Nombre del nino/a:_____________________________________Edad:___________
Fecha de Nacimiento:____________________________________
1. El nino usa su(s) audifono(s) todos los dias mientras esta despierto? ________
Si no es asi, la familia del nino hace todo lo posible para aumentar el tiempo en
el que el nino use su(s) audifono(s)?__________________________________________
_______________________________________________________________________________________
2. El nino/la familia estan comprometidos a darles mantenimiento al/los
audifono(s),incluyendo visitas al Audiologo?_____________________________________
________________________________________________________________________________________
________________________________________________________________________________________
3. El nino/la familia estan comprometidos a participar regularmente en
terapias sugeridas o requeridas. Tambien, en programas academicos o algunos
en casa para apoyar el desarollo de comunicacion?____________________
_______________________________________________________________________________________
_______________________________________________________________________________________
4. Este nino/familia demuestra necesidad economica?_________________________
_______________________________________________________________________________________
5. Comentarios Adicionales:_______________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Esta informacion se mantendra confidencial. Por favor mande esto por
fax a Mary Ceglio al 915-242-8397.

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