docEn 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.
