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Enrol Now!

Spots are limited so please fill out the enrollment form below to secure your child’s place in the program.

Student Details
First name
Surname
Date of birth

       
Name of school
School year in 2010
Residential Information
Street address
City/suburb
State
Post code
Parent/Guardian Details
Parents' Name(s)
Day phone (incl. area code)
Mobile
Email
How would you prefer to be contacted
If "other" selected, please state
How were you made aware about Hear For You?
Audiological Information
Degree of hearing loss Mild
Moderate
Severe
Profound
Do you wear hearing
aid(s)?		 Yes - How many
No
Do you have a cochlear implant? Yes - How many
No
Do you have any other disability in addition to hearing loss? Yes
No
If yes, please explain
Mode of Communication
The Hear For You program is designed for students whose primary mode of communication is spoken language. So that we may know more about you, please select your method of communication that you use in your daily communication and/or educational environments. Include any comments you want the Hear For You Program Directors to receive regarding your use of these methods.
Communication Mode Spoken language
Sign language
Other
If other, please explain
All information collected will remain confidential and only used by Hear For You.
Agreement
This is to certify that I am the parent or legal guardian of:
I give permission for my child to participate in the Hear For You program. It is understood that I will be held responsible for the payment of the program fee and any other expenses incurred by my child during their participation in the Hear For You program. I have read the Policies and Procedures and understand the information presented. I hereby release and indemnify Hear For You including each of its officers, directors, employees and volunteer staff from all claims which I and/or my child may have and from and against all liability arising out of or in connection with the Hear For You program and my child's participation therein.

By typing my name below, I acknowledge that I have read, understood, and accept this Agreement and affirm that all the information provided in this Enrollment Application is true and correct to the best of my knowledge.
My full name
Date
I confirm I have read the Policies & Procedures of Hear For You Yes

Click to access the Policies & Procedures (opens in new window)
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