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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 2013
Which program would you like to enrol in?
Residential Information
Street address
City/suburb
State
Post code
Parent/Guardian Details
Parents' Name(s)
Phone
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
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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