Application to participate in Listen to Me! Kenya Conference 2024

Conference dates are September 27-29, 2024

Deadline to apply: July 31, 2024

Child

First Name*

Last Name*

Date of Birth*

Gender*

Female

Male

Parents

Parent 1 last name*

Parent 2 first name*

Parent 1 first name

Parent 2 last name

Email address*

Mobile phone number*

Please enter your phone number in the following format:

"+254-20-1234567"

(where "20" is an example of an area code in Kenya).

Postal address

P.O. box*

P.O. box: Post code*

County

Select

Physical address

County*

Select

Physical address: Town*

Attending parent*

Parent 1

Parent 2

Both

Other primary caregiver(s)

Other primary caregiver(s) attending

Date of hearing loss diagnosis*

Cause of child hearing loss*

Where does your child receive audiology/medical services for his/her hearing aid/cochlear implant?

Clinic name*

Clinic city*

Clinic county*

Select

Please describe your child's hearing

Right Ear

Right ear type of loss*

Sensorineural

Conductive

Mixed

Not applicable/ unsure

Right ear device*

Hearing Aid

Med-El Cochlear Implant

No device

Right ear device date received*

Right ear: date child started wearing this device*

Left Ear

Left ear type of loss*

Sensorineural

Conductive

Mixed

Not applicable/ unsure

Left ear device*

Hearing Aid

Med-El Cochlear Implant

No device

Left ear device date received*

Left ear: date child started wearing this device*

I want my child to communicate using...*

Listening & Spoken Language Only

Sign Language Only

Sign Language & Spoken Language

Do you have other children who will participate in the sibling group?*

Yes

Maybe

Names and ages of all children participating*

Please list all the names and ages - one child per line

Service providers working with you and your child

Audiologist name*

Audiologist institution*

Audiologist email

Audiologist phone number*

Please enter your phone number in the following format:

"+254-20-1234567"

(where "20" is an example of an area code in Kenya).

Teacher of the deaf professional name*

Teacher of the deaf professional center

Teacher of the deaf professional email

Teacher of the deaf professional phone number

Please enter your phone number in the following format:

"+254-20-1234567"

(where "20" is an example of an area code in Kenya).

Teacher of the deaf professional minutes per week

Teacher of the deaf professional service method

Listening & Spoken Language

Sign + Speech

Sign Language

Speech-language pathologist name

Speech-language pathologist center

Speech-language pathologist email

Speech-language pathologist phone number

Please enter your phone number in the following format:

"+254-20-1234567"

(where "20" is an example of an area code in Kenya).

Speech-language pathologist minutes per week

Speech-language pathologist service method

Listening & Spoken Language

Sign Language

Sign + Speech

Other professional name

Other professional center

Other professional email

Other professional phone number

Please enter your phone number in the following format:

"+254-20-1234567"

(where "20" is an example of an area code in Kenya).

Other professional minutes per week

Other professional service method

Listening & Spoken Language

Sign Language

Sign + Speech

AUTHORIZATION FOR RELEASE OF INFORMATION

I, the undersigned, authorize the following institutions (check all that apply)*

Cochlear Implant Center

Audiologist

Child's school

Other service providers

Authorized Audiologist Name

Authorized Child's School Name

Authorized Other Service Providers Name(s)

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

Select

Name of other Authorized Employee

to: The Listen to Me! Conference and its employees.

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

This authorization shall expire no later than exactly one year after I submit this application or upon termination of my child’s enrollment in the Listen to Me! Conference (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.

If You are a Provider and Filling This Application on Behalf of the Family, Please TYPE YOUR NAME

YOUR SIGNATURE*

Type your legal name to sign this form electronically.

Confirm Your Signature*

The cost for attending Listen to Me 5,000 Shillings per family

To complete the registration, please submit 5,000 Shillings.

Submit payment to

Hearing Implants Limited:

Lipa na Mpesa

Paybill 600100

Account-0100004702907

Please note, your application will not be confirmed until payment has been submitted. THANK YOU!

Send me a copy of my responses

Privacy Notice|Report Abuse