Listen to Me! Hawaii 2024 - Reunion Family Application

Listen to Me! Hawaii 2024 - Reunion Family Application

We are thrilled to host our second LTM Hawaii Reunion weekend event for all previous attending Listen to Me! Hawaii families. Although it includes time to reconnect with old friends, the reunion weekend is packed with educational presentations, parent training rotations, discussion groups, and a family support group.

This year we are offering 2 ticket options:

Attend in-person (but arrange own housing/commute)
Attend in-person and stay in provided hotel on site

* Space is very limited so apply soon for this option! *

Costs will range from $50--$150 per family, depending on household income. Discounted rate for arranging own housing.

The LTM Reunion is designed to continue educating and supporting parents as they continue on their journey of having a child with hearing loss, acknowledging that families have different needs than they did when attending the initial Listen to Me! week.

Conference dates are: November 9th - November 10th, 2024

Deadline to submit: October 4th, 2024

Parent / Guardian

Name of Parent/Caregiver completing this form*

Please provide the names of all parents/caregivers who will attend the LTM Reunion

Name of Parent/Caregiver 1 attending the LTM Reunion*

Name of Parent/Caregiver 2 attending the LTM Reunion

Current Address

Address Line 1*

Address Line 2

City*

State*

Select

Zip Code*

Phone Number*

Email*

Child

Name of your Child with Hearing Loss*

Date of Birth*

Child's Current Age*

How many other siblings will participate?*

Select

Sibling (Name, Age)*

Sibling 2: Name, Age*

Sibling 3: Name, Age*

Siblings: Name, Age*

Primary language spoken by your family

Select or enter value

The cost for attending Listen to Me is based on a sliding fee scale

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

Annual Household Income*

Select or enter value

# of People in Household*

Lodging

Would you like to stay at the provided hotel or arrange your own housing?*

Select or enter value

Personal Appearance Release

I authorize Producer to record and edit into the Program and related materials my name, likeness, image, voice, interview (the “Recordings”). Producer may use and authorize others to use all or parts of the Recordings. Producer, its successors and assigns shall own all right, title and interest, including copyright, in and to the Program, including the Recordings, to be used and disposed of without limitation as Producer shall in its sole discretion determine.

PERSONAL APPEARANCE RELEASE*

Persons Appearing (List all family members participating):

Allergy Information:

Name of person(s) in family with allergies we should be aware of:

Allergic to:

Emergency Contact

Emergency Contact Name*

Emergency Contact Phone Number*

Listen To Me! Hawaii 2024 Reunion - Parent Authorization

Signature Authorization - Parent / Guardian*

Send me a copy of my responses

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