Application for a Sound Processor (aka BAHA device)

If you or a loved one has Microtia Atresia, and in need of a Sound Processor, please complete the following application for consideration. 2 ears 2 learn receives used sound processors from donors all across the United States. These used sound processors are then sent to the manufacture to be refurbished prior to us providing them to children in need.

For consideration, please complete the application as complete as possible. The child must have Microtia Atresia and children between the ages 4-10, and those with the greatest need are given the highest priority. Due to demand, not all applications will be approved.

This is a needs based program and therefore financial and healthcare insurance information is required in order for us to make a final determination. However, you are encouraged to complete the application regardless of your financial situation and your healthcare insurance situation as we might be able to find other resources to help you.

Patient/Child Information

  







Parent/Guardian Information


  

 
 
 



  

  
 
 

Financial Information




School Information



  
 
 


Healthcare/Insurance Information









 

By submitting this application I/we acknowledge a 2 Ears 2 Learn representative will contact me via phone and/or email to discuss the application and I/we give my/our consent to such contact even if we are on the National-Do-Not-Call List. I/we also acknowledge that additional supporting documentation (tax returns, consent forms, etc.) may be required in order for 2 Ears 2 Learn to fully process this application. I/we also acknowledge that 2 Ears 2 Learn does not guarantee this application will be accepted and I/we agree to accept the determination of 2 Ears 2 Learn as final and without further action.

Please click this link to download a hard-copy of this application