Listen to Me! 2016 Maximizing listening & spoken language for children with cochlear implants

Family Conference: June 19-24, 2016

"Stanford Oval May 2011 panorama" by King of Hearts

Families: June 19-24 Your child can learn to listen and speak. Join us at the Listen to Me! Summer Institute and learn how to make it happen. Our comprehensive training educates, empowers, and supports parents to teach their child to listen and speak.

Professionals: June 21, 22, 23 Invite your child’s service providers to attend too! (separate application) Professional track is designed for Teachers, Speech-Language Pathologists, Deaf & Hard of Hearing Specialists, Audiologists, and Administrators to learn more about using a listening & spoken language approach for children with hearing loss.

www.bakerinstituteforchildren.org

Where is LTM located? • Listen to Me! Summer Institute is located on the beautiful Stanford University campus. The family participants reside in one of the

large student houses on Mayfield Avenue (or may opt to arrange own housing & commute daily). Educational presentations take place in the Koret Pavilion at Hillel, located at 565 Mayfield Avenue, Stanford, CA.

Who is eligible for the LTM Family Conference? • Families with a child who is between 0 and 5 years old (must not turn 6 before July 1). • Child must wear a cochlear implant or be under consideration for one by a cochlear implant center in California. • Family (including at least one parent/guardian) must commit to staying the whole week of Listen to Me! Summer Institute.

How do I apply? • Fill out attached application and send with $50 deposit to: ATTN: Julie Cooper, Stanford Ear Institute, 2452 Watson Court, Suite

1700, Palo Alto, CA 94303

• A $50 deposit is required to apply. Please write checks out to: Stanford Otolaryngology - Head & Neck Surgery.

• If your family is selected, this $50 will be applied to your registration fee (which is based on a sliding scale). If your family is not selected this year, your $50 fee will be refunded to you. In the event that the Baker Institute selects your family to attend but you decide not to attend, the deposit will not be refunded.

• APPLICATIONS & DEPOSITS ARE DUE MARCH 1ST.

How much does it cost? • The cost for families to attend Listen to Me! is based on a sliding fee scale (based on annual household income).

• Please note that our top priority is to help families who need this most, so DO NOT LET COSTS PROHIBIT YOU FROM APPLYING. We will work with your family to pay only as much as you are able without it becoming a financial burden to you. Please contact Julie Cooper for any questions about this policy: ltm@bakerinstituteforchildren.org.

How are families selected? • The Listen to Me! Summer Institute has a limited number of openings. We currently accept 15 families per year. Priority is given to

families in greatest need of resources, information, and/or access to intervention services. We do keep a waiting list.

• Accepted families are notified by mail, usually on or soon after May 1st. Your acceptance letter will include the registration cost for your family, according to our sliding fee scale based on annual household income.

• After you have received an acceptance letter, you must mail in the requested registration fee to hold your family's place. If we do not receive your registration fee by May 15th, we will have to give your spot to a family on our waiting list.

What are the accommodations like? • All of the families stay together in one house, but each family sleeps in their own private room (or two neighboring rooms).

• Rooms are simply furnished with twin beds, dressers, and desks. Community bathrooms and showers are available on each floor.

• All bedrooms are located on the 2nd and 3rd floors of the house, with stair access. The houses are not air-conditioned, but fans are provided in each room.

• Stanford Catering provides 3 meals each day. Microwave, coffee maker, refrigerator, and freezer are available in the community kitchen.

Conference DescriptionThe Listen to Me! Summer Institute (LTM) is an intensive training program for families

and professionals to learn how to maximize listening and spoken language development with cochlear implants.

Bring the whole family! PARENTS participate in educational presentations, therapy and class observations, small group trainings, and a parent support group. CHILDREN participate in a class setting and receive daily listening and spoken language therapy. SIBLINGS who have normal hearing participate in a summer camp

experience designed just for them, including crafts, games, and outdoor activities.

June 19-24, 2016 — 565 Mayfield Avenue — Stanford — California — 94305 — www.bakerinstituteforchildren.org

Sunday, June 194:00—5:00 pm Registration and check-in

5:15—5:30 pm Opening: Welcome & Introductions

5:30—6:15 pm Dinner

6:15—7:00 pm Orientation & tour of conference facilities

Family Conference Schedule

Monday, June 208:30—8:45 am Music Session: Music & Singing to Develop Auditory Detection: Karen Erickson, DHHS

9:00—9:15 am Listen to Me! Mission & Overview: Julie Cooper, MS, CCC-SLP, LSLS Cert AVT

9:15—10:45 am Great Expectations—Parenting Children With Hearing Loss: Jenn Parenti, MA

11:00—12:30 pm Setting the Stage for Listening: Gabriela Holzman, M.A., Ed.

12:30—1:20 pm Lunch

1:30—2:30 pm MIRAH (Making It Real At Home): Teaching your child to listen & talk during kitchen routines

2:45—4:15 pm Parent Support Group: Adeline McClatchie, LCST., Dip Aud., CCC-A CSHA Fellow

Tuesday, June 218:30—8:45 am Music Session: Music & Singing to Develop Vocal Intensity: Karen Erickson, DHHS

9:15—10:45 am Cochlear Implantation: Surgery, Post-op, Complications, Bilateral Implantation, EAS/Hybrid, Future Directions, Stem Cell Research: Nikolas Blevins, MD, & Dylan Chan, PhD, MD

11:00—12:30 pm Repetition, Repetition, Repetition: Gabriela Holzman, M.A., Ed.

12:30—1:20 pm Lunch

1:30—2:30 pm MIRAH (Making It Real At Home): Teaching your child to listen & talk during bath time

2:45—4:15 pm Parent Support Group: Adeline McClatchie, LCST., Dip Aud., CCC-A CSHA Fellow

Wednesday, June 228:30—8:45 am Music Session: Music & Singing to Develop Rate/Tempo for Speech: Karen Erickson, DHHS

9:15—10:45 am Integrating Audition into Speech Therapy & Home Routines: Jennifer Aguilar, MS, CCC-SLP

11:00—12:30 pm Building Interest to Listen and Talk: Gabriela Holzman, M.A., Ed.

12:30—1:20 pm Lunch

1:30—2:30 pm MIRAH (Making It Real At Home): Teaching your child to listen & talk during bedtime routines

2:45—4:15 pm Parent Resource Binder & Shared Learning Activity: Gabriela Holzman, M.A., Ed.

Family Conference Schedule (cont’d…)

What previous attendees had to say about LTM: “Attending LTM institute was a huge game changer in our life. All the topics covered were

incredibly helpful, educational and motivational. Most of all, it was wonderful to meet and talk to other families who were in the same situation as us. There is no other place where you can receive so much information (on how to support children with hearing loss) in one place and in one week. It helped us to focus our energies on our son and armed us with the tools we needed to be effective

advocates for him in his journey.” —2013 Parent Alumni

“Attending LTM was such a great learning experience! Our son had just been implanted and turned 12 months old when we attended in 2011. We had gathered some knowledge about CI's

prior to LTM, but after attending we were amazed at how confident we felt about going forward. LTM truly lays out a path for you and your child to succeed post surgery. Specifically we loved the

individual therapy that was provided, MIRAH (Making It Real At Home), and connections we were able to make with other parents.” —2011 Parent Alumni

Thursday, June 238:30—8:45 am Music Session: Music & Singing to Develop Appropriate Vocal Quality: Karen Erickson, DHHS

9:15—10:45 am Special Education Law: Amy Henderson Brown, JD

11:00—12:30 pm Keep Them Engaged: Gabriela Holzman, M.A., Ed.

12:30—1:20 pm Lunch

1:30—2:30 pm MIRAH (Making It Real At Home): Teaching your child to listen & talk during bedtime routines

2:45—4:15 pm Jenny McCall, President & Chair of Baker Institute for Children with Hearing Loss, shares founding story

Friday, June 248:30—8:45 am Music Session: Music & Singing to Develop Listening & Spoken Language: Karen Erickson,

DHHS

9:00—9:20 am Next Steps: Listen to Me! Extension, Baker Scholars, and BabyTalk, follow-up communication & special events: Julie Cooper, MS, CCC-SLP, LSLS Cert AVT

9:30—10:15 am Raise the Bar!: Gabriela Holzman, M.A., Ed.

10:15–12:30 pm Parent Exit Meetings

12:30—1:20 pm Lunch

1:30—2:30 pm MIRAH (Making It Real At Home): Teaching your child to listen & talk during bedtime routines

2:45—4:15 pm Parent & Child Panel: Parents & children with CIs share their stories

4:15—4:30 pm Closing

June 19-24, 2016 — 565 Mayfield Avenue — Stanford — California — 94305 — www.bakerinstituteforchildren.org

Presenter BiosOUR DISTINGUISHED PRESENTERS ARE SOME OF THE LEADING EXPERTS IN THE FIELD

Nikolas H. Blevins, M.D. Dr. Blevins is the Malcolmson Professor of Otolaryngology at Stanford and is Chief of the Division of Otology/ Neurotology. He has been the the director of the Stanford Cochlear Implant Center since 2003. He received his bachelor's degree from Stanford University in biology before traveling to Boston to complete his medical training at Harvard. He then completed his residency in Otolaryngology at the University of California at San Francisco, and he remained at UCSF for additional fellowship training in otology/neurotology. Dr. Blevins joined the Otolaryngology Department at Tufts University in Boston as Chief of the Division of Otology and Neurotology. In 2003, he returned to California to join the Stanford Department of Otolaryngology. He specializes in disorders of the middle ear, inner ear, facial nerve, and skull base, and he is dedicated to the application of the most advanced technology to hearing restoration. Dr. Blevins has an active research interest in innovative surgical methods and the application of computer technology to surgical education and preoperative planning.

Dylan Chan, Ph.D., M.D. Dr. Chan is a pediatric otolaryngologist at the University of California San Francisco Medical Center. He graduated summa cum laude from Yale University with degrees in Molecular Biochemistry and Biophysics, and in Music. Dr. Chan then completed his medical training at the Weill Medical College of Cornell University, as well as a PhD in auditory physiology with Dr. A. James Hudspeth at the Rockefeller University. His post-graduate training has included a residency in otolaryngology-head and neck surgery at Stanford University as well as a fellowship in pediatric otolaryngology at Seattle Children’s Hospital. He has authored numerous peer-reviewed publications and presented his research on cochlear physiology and the genetics of hearing loss at multiple national meetings. His major interest is in hearing and deafness, especially congenital and acquired hearing loss, chronic ear disease, and cochlear implantation. In addition to his clinical practice, he runs a basic-science laboratory devoted to studying how genetic abnormalities lead to hearing loss and developing ways to treat deafness using gene therapy.

Julie Cooper, M.S., CCC-SLP, LSLS Cert. AVT Julie Cooper is the executive director of the Listen to Me! Summer Institute and the Baker Scholars Program at Stanford Ear Institute. She was instrumental in the creation and development of Listen to Me! in 2009, and she has directed the program every year. Julie served as the speech-language pathologist on the cochlear implant team at Stanford from 2008 to 2013. Additionally, Julie has worked at the Weingarten Children's Center since 2007 and continues to provide listening and spoken language (LSL) therapy there part-time. She earned a BA from Calvin College and an MS in speech-language pathology at the University of North Carolina at Chapel Hill. Julie has mentored several professionals seeking to specialize in a LSL approach through the FIRST YEARS program at UNC, PPCI, and local SLP graduate programs. She has presented at ACIA, ASHA, and San Jose State University.

Gabriela Holzman, M.A., Ed. Gabriela Holzman has been teaching the deaf and hard of hearing for over 20 years. She has taught in Mexico, California, Idaho and Washington. Gabriela holds a Master of Arts in Special Education: Communication Handicapped and a dual teaching credential for Regular and Bilingual, Cross-Cultural Education from K-8, from the states of CA, ID and WA. Gabriela has presented multiple times at AG Bell Conventions, Professional Preparation in Cochlear Implants (PPCI), Philadelphia Children’s Hospital, Let Them Hear Foundation, and various school districts. Her most recent professional endeavors include coordinating the parent section for Listen to Me! Summer Institute and working on the Listen to Me! development team since it began in 2009.

Kathy Mastrini, M.A. Kathy Mastrini is the Deaf & Hard of Hearing Specialist for Cupertino Union School District. She has worked with children ages 3 years to 8th grade, their families, and the teachers throughout the district since 2007. Previously, Kathy worked as a teacher, therapist, and principal at Weingarten Children’s Center for over 17 years. She has been the Coordinator of Professional Instruction for the Listen to Me! Summer Institute since its inception in 2009, as well as serving on the Listen to Me! development team each year. Kathy has presented on a variety of topics related to children with hearing loss to parents and professionals.

Jennifer Parenti, M.A. Jennifer Parenti is the Consumer Outreach Manager for Med-El, the hearing implant company. At Med-El, she provides support and education to cochlear implant candidates, recipients, and the professionals who support them in the West. Jennifer was the educational consultant to the cochlear implant team at Stanford from 2008-2014. She was the director of the Baker Scholars Program at Stanford for 5 years. She has also been a member of the development committee and a presenter for Listen To Me since 2010. Jennifer is a teacher of the deaf and earned a BA in Audiology from the University of Northern Colorado, a Masters in Special Education from San Francisco State University, and a CA Credential for Deaf/Hard of Hearing. Through the years Jennifer has

taught in both total communication and auditory oral classrooms in the Bay Area, including Weingarten Children's Center, San Francisco Unified School District, and Oakley Union Elementary School.

Adeline Clingan McClatchie LCST., Dip Aud., CCC-A CSHA Fellow Adeline McClatchie acquired her degree in Speech Pathology from Leicester University and her audiology degree from Manchester University, England. Adeline specialized in Pediatric Audiology and created the first clinical children’s audiology program in CO Antrim N. Ireland. She joined Children’s Hospital Oakland Speech and Hearing team in 1967 and became the director of Audiology at Children’s Hospital in 1969. During her 37 years in this position she introduced tympanic impedance measurement to Northern California and joined with Dr. Blair Simmons from Stanford to introduce the first infant hearing screening programs in the ICU setting. She established the routine clinical use (not research) of brain stem audiology for children and introduced real ear oto-emissions measurements as they emerged as a viable clinical tool. Under her direction the first cochlear implant program for children in Northern California was founded and funded in 1989 at Children’s Hospital Oakland in readiness for government approval of the use of cochlear implants in children in 1991. She has lectured locally, nationally and internationally and strongly supports the three prong approach of clinic, school and home to achieve best spoken language results from cochlear implant use in children.

Jennifer Aguilar, M.S., CCC-SLP Jennifer is a speech-language pathologist who has specialized in the deaf and hard of hearing population since 1998. She received her Master’s Degree in Communication Disorders from San Francisco State University and her Bachelor’s Degree in Business from the University of Wisconsin Madison. She has served children of all ages who have auditory processing, speech, language, and pragmatic difficulties at the Weingarten Children’s Center. She also maintains a certification to assess children and adults with Dyslexia. Jennifer is passionate about teaching to and learning from her students. She has conducted workshops and presented lectures to professionals, university students, and parents about working with children who are deaf or hard of hearing.

Amy Henderson Brown, J.D. Amy Brown began her career as an investment banker serving high technology companies. She transitioned to non-profit advocacy for individuals with hearing loss at the Let Them Hear Foundation. At LTHF, Amy and her colleagues appealed private, public and military health insurance denials nationwide resulting in people with hearing loss receiving over $35,000,000 in services. These wins ultimately resulted in insurance companies changing their making bilateral cochlear implantation available to most medically qualified individuals. Amy and the Advocacy Program then focused on improving the special education services for children with hearing loss. LTHF created a free internet-based resource center to explain key concepts of the Individuals with Disabilities Education Act (IDEA) to families. Amy continues to support special education advocacy work by serving families pro bono and by teaching at Listen to Me! Summer Institute, PPCI, and other organizations.

OUR MASTER CLINICIANS, EDUCATORS, & SUPPORT TEAM:

AUDIOLOGISTS: Sarah Coulthurst, MA, CCC-A

Kurt Kramer, AuD

Jannine Larky, MA, FAAA

Megan Loy, AuD

Colleen Polite, AuD

Austin Swanson, AuD

THERAPISTS: Trish L. R. Alba, M.S., CCC-SLP

Sayard Benvenuti, MA, CCC-SLP

Patricia Gomez, MS, CCC-SLP

Sharon Nutini, MA, DHHS

TEACHERS: Jan Christensen, MA, DHHS

Karen Erickson, DHHS

Joanie McLaughlin, MAT

SOCIAL WORK/COUNSELING: Meg Farquhar, MSW

VOLUNTEER COORDINATOR: Kandy Bergquist, MA, CCC-SLP

ENVIRONMENT COORDINATOR: Shalane Gargan, BA

SIBLING CAMP COORDINATORS: Shalane Gargan, BA, & Mary Kukla, BA

ADMINISTRATIVE ASSISTANTS: Lauren Greenwood, BA, & Arturo Manriquez

CLASSROOM ASSISTANTS: Alicia Sepulveda & Matt Nutini

INTERPRETERS: Angelica Aguilar, Bertha Lopez, Alejandra Otero

AV MANAGER: Chris Berger

Our FounderJennifer Jordan McCall President, Founder, and Chair of the Board

“Like all parents, when my first child was born I wanted her to have the happiest life possible. I was devastated when she couldn't learn to talk. Once I accepted the fact that Caroline couldn't learn to talk without medical help, it still took me almost 12 months to obtain a correct diagnosis and to get her the help she needed.

By this time, Caroline was already two and a half years old.

In search of a diagnosis (this was 1991) we saw psychologists, neurologists, cardiologists and oncologists. As it turned out, we found the help we needed from an otologist, an audiologist and a speech pathologist, as well as through group and individual speech therapy sessions.

During the critical formative years of her childhood, Caroline could not hear or learn to talk because she did not yet have hearing aids or a cochlear implant. This put her behind her chronological peers. Not just in terms of speech and language acquisition, but also in terms of her substantive learning, which is dependent on acquisition of language.

While Caroline eventually made substantial strides in closing the learning gap between her and her age group and while she went on to earn a university degree her struggle to perfect her language skills will always be a challenge.

Once I had finally obtained a diagnosis of her hearing loss, I wanted Caroline to learn to talk so she could attend a "mainstream" school and be able to attain a job of her choosing, with fewer challenges when communicating with the hearing population. This, too, is what we want for the children helped by the Baker Institute.

The Baker Institute aims to help families get the information they need without the undue delay which my family endured; and we want to ensure to the extent possible with our resources that the ability to pay for such services is not a barrier to any child being able to join his or her peers in our hearing and speaking world.” — Jennifer Jordan McCall

Jennifer Jordan McCall is a partner at the law firm Pillsbury Winthrop Shaw Pittman, LLP, based in Silicon Valley and New York, and she is the Chair of the Estates, Trusts & Tax Planning practice section. Pillsbury's Estates, Trusts & Tax Planning group ranked Tier 1 in US News/Best Lawyers for 2011. Pillsbury was named 2013 "Law Firm of the Year" for Trusts & Estates by U.S. News & World Report and Best Lawyers. Ms. McCall has been named by Chambers Directory as a National Leader in the fields of Trusts and Estates for 2006-2011 and by PLC Which Lawyer? for 2009-2011. She was recently nominated as one of only nine women in the United States as Wealth Management Lawyer of the Year. Furthermore, Ms. McCall was recently admitted to the Florida Bar and opened a new Palm Beach office.

In addition to Ms. McCall's work with the Baker Institute, she serves as Secretary of the Board of Trustees of the San Francisco Ballet, is a member of the Planned Giving Committee of Princeton University, and serves as Trustee of several charitable foundations and charitable trusts.

Ms. McCall's daughter, Caroline Clark, was born with a hearing loss and uses two cochlear implants to listen and speak. Caroline is currently a successful spoken language communicator, and she is a 2011 Princeton University graduate. Because of Ms. McCall's experience with raising her daughter, she knows what it takes to help children with hearing loss succeed. She is passionate about helping other parents become empowered with the knowledge, skills, and resources necessary to make this possible for their own children.

To get a glimpse of Listen to Me! in action, check out the beautiful 10 minute documentary film on our website:

http://bakerinstituteforchildren.org/listentome/videos.html

Jennifer Jordan McCall founded the Baker Institute for Children with Hearing Loss in 2008. Since our inaugural Listen to Me in 2009, we have

empowered the families of 76 children with cochlear implants.

June 19-24, 2016 — 565 Mayfield Avenue — Stanford — California — 94305 — www.bakerinstituteforchildren.org

! APPLICATION: DUE MARCH 1, 2016

Child’s Name: Date of Birth: ___________________________________ _______________________

Parents’ Names: ___________________________________Phone Number: ___________________

Address:__________________________________________________________________________

Email address:_________________________________________Child is male or female:__________

Both parents are invited to attend the program. Will both parents be able to attend? yes no

If no, which parent will attend? _______________________________________________________

What is the primary language spoken by your family? ______________________________________

How would you rate your level of English proficiency? (Interpreters will be available if needed).

no English moderate English fluent in English

Please indicate device information:

What communication modality have you chosen for your child? (Auditory-Verbal, Auditory-Oral, Total Communication, American Sign Language, other?) ________________________________________

Please describe the intervention services your child is currently receiving: (Speech therapy, deaf/ hard of hearing services, early intervention?) How many times per week? ____________________________ _________________________________________________________________________________ _________________________________________________________________________________

Please state the name of your child’s school: _____________________________________________

Who are your service providers? (Speech-language pathologist, deaf/ hard of hearing teacher, audiologist) Name: Title: __________________________________ ___________________________________Phone Number: Email address: __________________________ ___________________________Work address: ______________________________________________________________________

Name: Title: __________________________________ ___________________________________Phone Number: Email address: ___________________________ ____________________________Work address: ______________________________________________________________________ _________________________________________________________________________________

Name: Title: __________________________________ ___________________________________Phone Number: Email address: ___________________________ ____________________________Work address: (over) _________________________________________________________________

Device (Cochlear, Advanced Bionics, Med-El, hearing aid)

Surgery location (Cochlear Implant Center)

Surgery date

Activation date

Right ear:

Left ear:

Do you have other children with normal hearing who will attend the sibling camp? yes no

If yes, please state those children’s names and ages: ______________________________________

_________________________________________________________________________________

The cost for attending Listen to Me is based on a sliding fee scale. Fees, lodging, all meals, and parking permits are included.

Please indicate your annual household income and family size in the table to the right.

A $50 application fee is required. If your family is selected to attend Listen to Me, we will apply the $50 toward your registration fee. If you are not selected, we will refund you the $50 application fee.

Please note that our top priority is to help families who need this most, so DO NOT LET COSTS PROHIBIT YOU FROM APPLYING. We will work with your family to pay only as much as you are able without it becoming a financial burden to you.

If your family is chosen to attend Listen to Me, we will notify you of the financial cost for your family according to the sliding fee scale. At that time, we will request advanced payment to secure your place (due in May). If you return your room key at the end of Listen to Me, you will receive a $100 refund.

We plan accommodations for families composed of 1-2 adult participants (parents or other primary caregivers), and 1-4 children in immediate family. If additional participants need to attend, please contact Julie Cooper for permission and cost (ltm@bakerinstituteforchildren.org).

Full refunds will be given if cancellations are made at least two weeks prior to the start of Listen to Me (on or before June 3, 2016). If cancellations are made after June 3, 2016, no refunds will be given.

PLEASE INCLUDE YOUR $50 DEPOSIT with this application. Write checks out to Stanford Otolaryngology-Head & Neck Surgery.

Please mail application to: Stanford Ear Institute ATTN: Julie Cooper 2452 Watson Court Suite 1700 Palo Alto, CA 94303

We’ll notify you after families are selected, on May 1, 2016.

The Baker Institute for Children with Hearing Loss does not provide medical services or medical advice of any kind to any person, directly or indirectly, and in consideration for the receipt of financial assistance from The Baker Institute for Children with Hearing Loss, all recipients of any such funding acknowledge the foregoing and release and hold harmless The Baker Institute for Children with Hearing Loss and its agents from all claims of any kind in connection with any medical services, advice, or therapy they may receive as a result of financial assistance provided by The Baker Institute for Children with Hearing Loss to any medical provider or to such persons.

√ Annual Household Income # People in Family

$15,000—$25,000

$25,001—$50,000

$50,001—$75,000

$75,001—$100,000

$100,001—$125,000

$125,001—$150,000

$150,001—$250,000

$250,001 +

AUTHORIZATION FOR RELEASE OF INFORMATION

Child’s Name: ______________________________ Date of Birth: _____/_____/_____

Mailing Address: _______________________________________________________

______________________________________________________________________

Phone: ( ) _______-_________ Email:_______________________________

I, the undersigned, authorize the following institutions:

❒ Cochlear implant center:____________________________________________

❒ Audiologist:______________________________________________________

❒ Child’s school:____________________________________________________

❒ Other service providers:____________________________________________

_____________________________________________________________

and their employees to disclose/release the following information from my child’s records

(check all that apply):

❒ Audiological Records ❒ Educational Records ❒ Surgical /Operative Records ❒ Speech-Language Evaluations/notes ❒ Occupational Therapy ❒ Medical Records ❒ Other: __________________________________________

to: The Listen to Me! Summer Institute and its employees.

I also authorize the Listen to Me! Summer Institute to contact me at the above phone number and addresses with correspondence that specifically relates to the Listen to Me! Summer Institute.

This authorization shall expire no later than: 7/1/ 2017 or upon termination of my child’s enrollment in the Listen to Me! Summer Institute (whichever is sooner). I understand that I may revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing. I understand that the revocation will not apply to information that has already been released in response to this authorization. By signing below I represent and warrant that I have authority to sign this document and authorize the use or disclosure of protected health information and that there are no claims or orders pending or in effect that would prohibit, limit, or otherwise restrict my ability to authorize the use or disclosure of this protected health information.

__________________________ __________________________ ____/_____/_20___ Signature of Parent/Guardian Printed Name of Parent/Guardian Date (mo/day/year)

Stanford Ear Institute - 2452 Watson Court, Ste 1700 - Palo Alto, CA 94303 - ltm@bakerinstituteforchildren.org bakerinstituteforchildren.org

Stanford Ear Institute 2452 Watson Court, Ste 1700

Palo Alto, CA 94303 ltm@bakerinstituteforchildren.org

bakerinstituteforchildren.org