Application for a Sound Processor (aka BAHA device)

If you or a loved one has Microtia and Aural Atresia, and are 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 and Aural Atresia and be between the ages of birth and 10 years old. 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

First Name:  Middle Initial:  Last Name: 
Date of Birth: 
Which ear needs a sound processor? 
Do you require a soft headband? 
Do you currently have a sound processor? 
If yes, which Make: 
Model: 
Please add a couple of paragraphs about your child so we can better understand their specific need:

Parent/Guardian Information

PARENT/GUARDIAN #1
First Name:  Middle Initial:  Last Name: 
Address: 
City:  State: Zip Code: 
Phone 1:  Email 1: 
Phone 2:  Email 2: 
Does the Patient/Child live with you? 



PARENT/GUARDIAN #2
First Name:  Middle Initial:  Last Name: 
Address: 
City:  State:  Zip Code: 
Phone 1:  Email 1: 
Phone 2:  Email 2: 
Does the Patient/Child live with you?

Financial Information

What is your estimated yearly gross household income (before all taxes and deductions)? 
Number of people living in the household as stated on your Federal Tax Return  

We may require a copy of your Federal Tax Return for verification.
Have you sought assistance and been approved by other public or private sources?

School Information

School Name: 
Address: 
City:  State:  Zip Code: 
Phone 1:  Email 1: 
Phone 2:  Email 2: 
School Contacts (please add teachers, administrators, specialist, etc.):

Do we have your permission to contact the school?

Healthcare/Insurance Information

Do you currently have Health Insurance 
If Yes, which company? 
Insurance ID#: 
If Yes, have you previously been denied coverage for a sound processor? 
If Yes, would you like us to contact them and try to get an approval? 
Has the Patient/Child had an Audiogram within the last 2 years? 
Does the Patient/Child currently have an Audiologist and/or Otolaryngologist?
If yes, please tell us who:
Name  Phone 
If no, would you like us to refer you to one?

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.

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