Hearing Loss Association of North Carolina Home - ALL ... Mission Packet.pdfStarkey Hearing...

Starkey Hearing Foundation 6700 Washington Ave. South Eden Prairie, MN 55344 1-800-769-2799

Dear Hearing Professional, We are very excited to be coming to Charlotte, North Carolina to help children receive the Gift of Hearing. We are inviting you to join forces and help us identify children who truly need this philanthropic effort.

Candidates for the Charlotte Mission will be approved utilizing the following guidelines created by the Starkey Hearing Foundation.

1. Recipients must be between the ages of 4 to 22 years. 2. Recipients must be of a low income family determined by

hearing professional and/or school administration; Eligible for Free Lunch Program

3. Current hearing devices must be older than 3 years. 4. Medical clearance must be issued by a licensed physician. 5. Full audiometric assessment, illustrating a valid pure tone test

with MCL, UCL, and word discrimination measurements must be provided with ear impressions by a NC licensed dispensing hearing professional.

6. Severe to profound losses must result in 3 thresholds to determine hearing aid benefit.

We have created a packet of information for completion. Please send this packet along with well defined earmold impressions to: ALL FORMS AND IMPRESSIONS MUST BE SUBMITTED BY APRIL 30TH 2010

Starkey Hearing Foundation 6700 Washington Ave. South

Eden Prairie, MN 55344 Attn: Charlotte Mission

We look forward to you in Charlotte! With great appreciation, The Starkey Hearing Foundation


The Starkey Hearing Foundation appreciates your assistance in reaching children in your area that cannot afford hearing aids. Candidates will be receiving the best in custom digital hearing aid technology.

For this Charlotte, North Carolina Mission, the following information is required by April 30th 2010:

Medical Clearance (waiver for 18 yrs. or older included. Children must have medical clearance from licensed

Physician attached to this form)

Parental Consent Form

A Photograph Release

A Hearing Aid Request Form

Current Hearing Evaluation (air conduction, bone conduction, speech discrimination, MCLs, and UCLs)

Well-defined impressions (by a NC licensed dispensing hearing professional)

With your help, we can bring the gift of sound to those in need. Your professional services and effort to locate these deserving individuals is greatly appreciated. For assistance, please contact: Melissa Di Stefano, MS, CCC-A or Justine Hammer, AuD. Audiologists Starkey Hearing Foundation 1-800-328-8602 ext. 2862


Dear Families, The Starkey Hearing Foundation is excited about bringing the gift of hearing to your child. Our organization began in 1973 with a simple premise: “Alone we can’t do much. But, together we can change the world.” It is our sincere wish to bring the joy of better hearing to your family. With the collaboration from your local hearing professionals, the Starkey Hearing Foundation will be fitting our best digital technology at our Charlotte North Carolina Mission on Monday, May 10th 2010 at the Charlotte Motor Speedway. Your child will be receiving our best, S Series digital hearing aids ($4000 value each aid) with 1 card of batteries, hearing aid accessories, and a Starkey Hearing Foundation T-Shirt. The foundation will cover all repairs on these FREE hearing aids for one year. Additional warranty on these aids can be purchased through your hearing professional or by Starkey Labs, directly. All future service will be handled through your hearing professional. In the case of loss or damage beyond repair, there is a $500 replacement fee for each hearing aid. Please encourage your child to take great care of these wonderful hearing aids. With good care and maintenance these hearing aids should last up to five years! This is a private event not affiliated with any private or public school. Any participation in this hearing aid mission is the sole responsibility of the parent or guardian of the hearing aid candidate. This includes working with a local audiologist for hearing aid preparations before the event, providing transportation for your child on the day of the event, and accompanying your child during the event. Please be aware that participation in the “free hearing aid mission” may NOT considered an excused absence from school. Looking forward to seeing you on Monday, May 10th 2010 at Charlotte Motor Speedway at 10:00 AM! Mission should conclude about 4 PM. Sincerely, Melissa Di Stefano, MS, CCC-A and Justine Hammer, AuD. Audiologists and Domestic Mission Coordinators Starkey Hearing Foundation www.sotheworldmayhear.org


Hearing Aid History Form

Patient’s Name: ________________________________________________ Age: _______ T-Shirt Size: ___________ Gender: Male / Female Name of Parent/Guardian: _____________________________________

Patient’s Phone Number: _________________________________

Referring Hearing Healthcare Provider: __________________________NC License #_______ Phone: ____________________________________________ Patient’s Skin Tone: ____________ Hair Color: ___________________ Primary Language: English__________ Other: ___________________ ASL: _____________ Audiometric Information Right MCL: ____________________ Left MCL: ____________________ UCL: ____________________ UCL: ____________________ **Does the patient need FM compatibility? _________________________ Previous Amplification: _________________________________________ Status of the devices currently worn: ____________________________ Previous history of auditory rehab/speech therapy: _______________ _______________________________________________________________

*****Please provide all information asked*****


Photograph Release

I grant permission to Starkey Laboratories, Inc., Starkey Hearing Foundation, on behalf of

Starkey Laboratories, Inc. and its agents or employees, to use photographs taken of me and/or

my child on the date and at the location listed below for use in publications such as brochures,

newsletters, and magazines, and to use the photographs on display boards, and to use such

photographs in electronic versions of the same publications or on Starkey Laboratories, Inc. web

sites or other electronic form or media, and to offer them for use or distribution in other related

publications, electronic or otherwise, without notifying me.

I hereby waive any right to inspect or approve the finished photographs or printed or electronic

matter that may be used in conjunction with them now or in the future, whether that use is

known to me or unknown, and I waive any right to royalties or other compensation arising from

or related to the use of the photograph.

I hereby agree to release, defend, and hold harmless Starkey laboratories, Inc. and Starkey

Hearing Foundation, on behalf of Starkey Laboratories, Inc. and its agents or employees,

including any firm publishing and/or distributing the finished product in whole or part, whether

on paper or via electronic media, from and against any claims, damages or liability arising from

or related to the use of the photographs, including but not limited to any misuse, distortion,

blurring, alteration, optical illusion or use in composite form, either intentionally or otherwise,

that may occur or be produced in taking, processing, reduction or production of the finished

product, its publication or distribution.

I am 18 years of age or older and am competent to contract in my own name. I have read this

release before signing below, and fully understand the contents, meaning and impact of this

release. I understand that I am free to address any specific questions regarding this release by

submitting those questions in writing prior to signing, and I agree that my failure to do so will be

interpreted as a free and knowledgeable acceptance of the terms of this release.

Please check one:

I agree to allow photographs under the terms above.

I do not agree to allow photographs under the terms above.

Child’s Name (please print) Child’s Signature (if 18 years of age or older)

Parent/Guardian Name (please print) Parent/Guardian Signature


WAIVER OF MEDICAL EVALUATIONS FOR HEARING AID(S)/EARMOLDS

I have been advised that the Food and Drug Administration (FDA) has determined that

my health interest would be served if I had a medical evaluation by a licensed physician

(preferably a physician who specializes in diseases of the ear) before acquiring a hearing

aid and/or earmolds.

I do not wish to have a medical evaluation before acquiring hearing aid(s) and/or

earmold(s).

Signature (candidate must be 18 yrs. or older to use this form) Date


Parent Consent Form Charlotte, North Carolina Mission

Hearing Aid Fitting Event Monday, May 10th, 2010

Charlotte Motor Speedway Dear Parents, The Starkey Hearing Foundation will be providing FREE hearing aids at the Charlotte Motor Speedway. We have selected several beneficiaries, including your child, ______________________________, who would benefit from this effort. In order to be eligible, we must first receive your consent allowing your child to participate. We will review their records for current audiometric evaluations and otological clearance from a medical doctor so hearing devices can be made. Your NC licensed dispensing hearing professional can help you submit all necessary paperwork and earmold impressions to the Starkey Hearing Foundation.

We need your permission in order to include your child in this wonderful opportunity. Please review and check the statement(s) below. Please sign and return it to your child’s contact (hearing professional) as soon as possible! My __________________________________child has the permission to: _____ receive otological clearance from a qualified medical doctor _____ receive audiological testing from a NC licensed dispensing hearing professional The hearing aids will only be fit at the: - Charlotte Motor Speedway. - Registration for all beneficiaries begins 10:00 AM and should conclude 4:00 PM. For the candidate mentioned above, I hereby authorize the checked options and for the release of pertinent medical information to the Starkey Hearing Foundation. ________________________________________ ___________________________ Signature of parent/legal guardian date ****Contact Telephone Number: _________________________________________


CHARLOTTE, NORTH CAROLINA MISSION WILL BE HELD ON MONDAY, MAY 10TH 10:00 AM AT THE CHARLOTTE MOTOR SPEEDWAY

From South Carolina:

• I-77 North to Exit 1 (I-485 East) • I-485 to Exit 32 • Right on Hwy 29 North/Tryon Street • Right on Morehead Road • PAID parking on right at Entrances M and O ($20) • FREE parking on right at Performance Drive and Entrance Q

From Harrisburg, N.C.

• Hwy 49 South to Morehead Road • Right at Morehead Road • FREE parking on left at Entrance Q

**Due to space limitations, we ask that each hearing aid recipient bring

one parent/guardian to the event. Lunch will be provided by the Starkey Hearing Foundation.

From Charlotte, N.C.

• I-85 North to Exit 46 A (Mallard Creek Church Road) • Right on Mallard Creek Church Road • Left at North Tryon Road (Hwy 29 North) • Right onto Morehead Road • PAID parking on right at Entrances M and O ($20) • FREE parking on right at Performance Drive and Entrance Q

From Charlotte, N.C.

• Hwy 29 North to Morehead Road • Right on Morehead Road • PAID parking on right at Entrances M and O ($20) • FREE parking on right at Performance Drive and Entrance Q

From Greensboro, N.C.

• I-85 South to Exit 48 (I-485 / Rock Hill) • Exit 32 and turn left on to Hwy 29 North/Tryon Street • Right at Morehead Road • PAID parking on right at Entrances M and O ($20) • FREE parking on right at Performance Drive and Entrance Q

CATS provide bus service from the Charlotte Transportation Center in Uptown Charlotte. Fans can take the 79X Concord Mills Express for just $6 roundtrip. To learn more about the 79X Concord Mills Express and CATS services, call (704) 336-RIDE (7433).


The following is a list of NC and SC licensed dispensing hearing professionals willing to assist families in preparations for this Charlotte Mission if needed. There may be costs associated with hearing services. Call first to inquire about these costs.

Randolph Audiology, Wade Kirkland AuD., 3535 Randolph Rd. Ste 211 Charlotte, NC 704-367-1999 Charlotte Speech and Hearing Center 210 E Woodlawn Rd. Suite 150 Charlotte, NC 28217 704-523-8027 Best Value Hearing Centers; 9 locations Morganton, NC: 423 South King St. Morganton, NC 28655 828-438-9685 Gastonia, NC: 1008 Union Rd. Gastonia, NC 28054 704-853-0360 Hickory, NC: 302 4th St. SW Hickory, NC 28602 828-322-9323 Wilkesboro, NC: 102 Elkin Hwy N. Wilkesboro, NC 336-838-8886 Statesville, NC: 851 North Center St. Statesville, NC 28677 704-878-2320 Lincolnton, NC: 112 Newbold St. Lincolnton, NC 28092 704-735-0028 Boone, NC: 163 Shadowline Dr. Boone, NC 28607 828-264-5296 Lenoir, NC: 116 Pennton Ave. SW Lenoir, NC 28645 828-754-2754


Hearing Healthcare Centers, 9 locations, Call 232-3999 Charlotte, NC: 5110 Park Rd. Suite 1C Charlotte, NC 28209 Charlotte, NC: 7903 Providence Rd. Charlotte, NC 28277 Hendersonville, NC: 2000 Spartanburg Hwy Hendersonville, NC 28792 Gastonia, NC: 635-C Cox Rd Gastonia, NC 28054 Lincolnton, NC: 231 N. Generals Blvd Lincolnton, NC 28792 Huntersville, NC: 16300 Statesville Rd. Huntersville, NC 28078 Spartonburg, SC: 233 E. Blackstock Rd. Suite H Spartanburg, SC 29301

Greenville, SC: 331 Mills Ave. Greenville, SC 29605 ENT Carolina, 3 locations Gastonia, NC: 2520 Aberdeen Blvd. Gastonia, NC 28054 704-868-8400 Shelby, NC: 1180 Wyke Rd. Shelby, NC 28150 704-487-9100 Belmont, NC: 1212 Spruce St. Suite 207 Belmont, NC 28012


Queridos Padres,

La Fundación Auditiva Starkey atravez de este medio les ofrece una

invitacion a sus hijos para recibir la opportunidad de una mejor audicion. Nuestra organización comenzó con una premisa simple: "Solos no podemos hacer mucho…Pero, juntos podemos cambiar el mundo".

Basado en las palabras de nuestro fundador el Sr. William Austin; "Para

nosotros es importante ayudar a los niños, ya que ellos representan el futuro del mundo – y si descuidamos a los niños, disminuimos nuestro futuro. Esto es algo muy especial que le ofrecemos a los niños. Es un acto que siempre recordaran. Nuestra recompensa se vera en los rostros y sonrisas de cada persona, debido a su capacidad de escuchar de nuevo. Este es el mejor trabajo que podríamos hacer, porque nos estámos ayudando uno al otro y de eso es lo que la vida esta sobre basada. Realmente vivimos nuestra vida atravez de lo que damos – y viviremos en el futuro, a través de nuestros regalos a nuestra comunidad y a la humanidad".

Es nuestro sincero deseo de compartir con su familia la alegría a partir de obtener una mejor audicion. La Fundación Auditiva Starkey estara el Charlotte Motor Speedway en Charlotte, NC a las 10:00 en la manana. La fecha es el Lunes, 10 de Mayo, 2010. En esta misión los audífonos seran donados, libre de todo costo, a los beneficiaries y sus familia. La Fundacion estara proveyendo los auxiliares debido en parte a el apoyo de los egresados de la NRA, Charlotte Motor Speedway Charities y a los otros patrocinadores corporativos que rodean el evento.

Se trata de un evento privado no afiliado con las escuelas públicas del North Carolina. Cualquier participación en esta misión de entrega de audífonos es la responsabilidad exclusiva de los padres’ o tutores del beneficiario. Esto incluye: trabajar con su audiólogo para obtener la evaluacion y preparativos antes del evento - proporcionar transporte para su hijo/a en el día del evento y estar presente y acompañando a su hijo/a durante el transcurso del evento. Atencion: Quienes asistan a esta misión de entrega de audífonos, no seran excusados de una ausencia de la escuela. Cada uno de los candidatos elegible para este evento, recibirán modelos de audífonos marca Starkey con la tecnología más reciente de la Serie S y tecnología de Sweep. El valor aproximado de dicho aparato es $ 4.000 USD por cada audífono. Si desean obtener más información acerca de esta tecnología, por favor de Visitar nuestra pagina www.starkey.com y www.sotheworldmayhear.org para mas información sobre la Fundación Auditiva Starkey.

http://www.starkey.com/

http://www.sotheworldmayhear.org/


Formulario de Solicitud para Audífonos

Nombre del Paciente: ________________________________________________ Edad: _______ Talla de camisa: ___________ Nombre del Padre/ Guardián: _____________________________________

Numero telefónico del paciente: _________________________________

Proveedor de Cuidado de Salud que lo refirió: ____________________Licencia del NC #_______ Teléfono de Proveedor: _________________________________ Tono de piel del paciente: ____________ Color del Cabello: ___________________ Idioma principal: Ingles__________ Otro: ___________________ ASL: _____________ Previous history of auditory rehab/speech therapy Información Audiométrica Derecho MCL: ____________________ Izquierdo MCL: ____________________ UCL: ____________________ UCL: ____________________ ¿Necesita el paciente compatibilidad para el FM? _________________________ Amplificación previa: _________________________________________ Estado de los dispositivos que el paciente usa en este momento: _________________ _____________________________________________________________________ Historia previa de rehabilitación auditoria/ terapia de habla/lenguaje: _______________ ______________________________________________________________________

*****Por favor de proveer toda la información en la forma*****


Permiso de Fotografía Yo doy permiso a Starkey Laboratories, Inc., Starkey Hearing Foundation, de parte de Starkey

Laboratories, Inc. sus agentes y empleados, a usar fotografías de mi y de mi niño/a en la fecha y

locación listada abajo en publicaciones como folletos, boletín de noticias, y revistas, y usar en

pizarrones, y usar estas fotografías en publicación electrónicas de la misma, o en los Laboratorios

de Satarkey Inc., en paginas electrónicas o en otro medio, y ofrecer estas para uso o distribución

en otras publicaciones relacionadas a este, electrónicos o de otra manera, sin notificarme.

Yo renuncio el derecho de inspeccionar o de aprobar el producto final de las fotografías,

impresiones impresas o en objetos eléctricos que sean usados en el evento o en un futuro, por lo

tanto no sabré el uso de estos, y renuncio el derecho de poder de estos y de ningún tipo de

compensación que se lleven por estos o su uso en otra manera.

Por la presente, doy permiso de liberación, defiendo y confío en los Laboratorios de Starkey Inc. ,

y sus agentes y empleados, incluyendo cualquier entidad publicando y/o distribuyendo el

producto final en su totalidad, ya sea en papel o en vía electrónica , de cualquier queja, los danos

o responsabilidad que se lleguen por estas o relacionado al uso de las fotografías, incluyendo

pero no limitando , a cualquier mal uso, distorsión, difuminacion, alteración, opción o uso en

forma compuesta, ya sea intencional o no sea así, esto puede ocurrir en procesamiento o,

reproducción de el producto final, de su publicación o distribución.

Yo tengo 18 anos de edad o mayor y tengo la competencia de representarme por mi mismo/a.

Yo he leído reste permiso antes de firmar abajo, y entiendo completamente el contenido,

significado y el impacto de este permiso. Yo entiendo que estoy en libertad de hacer preguntas

especificas acerca de este permiso al entregar estas preguntas por escrito antes de firmar este

permiso, estoy de acuerdo que si no lo hiciese así, esto será interpretado como si lo entendiese

este permiso y estoy aceptando todos los términos mencionados en este.

Please check one:

Yo estoy de acuerdo de permitir tomar fotografías bajo estos términos.

Yo no estoy de acuerdo de permitir tomar fotografías bajo estos términos.

Nombre del Niño/a (letra de molde) Firma del Niño/a (si es mayor de 18 anos de edad)

Nombre del Padre (letra de molde) Firma del Padre o Guardián


PERMISO DE EVALUACIONES MEDICAS PARA AUDIFONO(S) Y MOLDES

Se me ha informado que la Food and Drug Administration (FDA) ha determinado que

los intereses de mi salud serán servidos si yo tuviese una evolución por un doctor

licenciado (preferiblemente un doctor que se especializado en enfermedades de el oído)

antes de adquirir un audífono y/o moldes.

Yo no deseo tener una evaluación médica antes de adquirir audífono(s) y/o moldes(s).

Firma Fecha


Forma de consentimiento del padre/guardián

10 de Mayo 2010 Charlotte Motor Speedway

Hearing Aid Fitting Event

Queridos Padres, La Starkey Foundation estará proveyendo audífonos GRATIS en (la ubicación para ser determinada). Hemos seleccionado diferentes beneficiados para este, incluyendo a su niño(a) ______________________________, quien se beneficiaria de este esfuerzo. Para poder ser elegible, nosotros necesitamos primero recibir su permiso diciendo que su niño/a pueda participar. Revisaremos sus registros médicos, si tienen evaluación audiométricas y si tienen certificación medica de su doctor para poder hacerle dispositivos de audición. Su audiología proveerá todas las formas necesarias e impresiones del oído a la Starkey Hearing Fundación.

Los audífonos serán ajustados solamente en el Charlotte Motor Speedway, en Charlotte, NC a las 10:00 en la mañana. 10 de Mayo 2010

Necesitamos su permiso para poder incluir a su niño(a) en esta maravillosa oportunidad. Por favor compare las declaraciones siguientes. Por favor firme y regrese a su persona de contacto (audiología) lo mas pronto posible! __________________________________Mi niño(a) tiene el permiso de: _____ permiso de recibir servicios otológicos de un doctor medico calificado. _____ Permiso de recibir servicios exámenes audiológicos de una profesional de la audición que tiene una licencia de la Carolina Norte para dispensar audífonos. _____ estar disponible el 10 de Mayo de 2010, para estar presente para poder recibir los nuevos, audífonos a no costo. La registración empieza a las 10:00 AM. A los candidatos mencionados anteriormente, Yo autorizo a la compañía la liberación de la información médica pertinente a la Starkey Hearing Foundation. ________________________________________ ___________________________ Firma del padre o guardián Fecha Número telefónico de contacto: _________________________________________

Hearing Loss Association of North Carolina Home - ALL ... Mission Packet.pdfStarkey Hearing...

Documents

Transcript of Hearing Loss Association of North Carolina Home - ALL ... Mission Packet.pdfStarkey Hearing...