Listen to Me! California Conference for New Families

Conference dates are June 22-27, 2025

Deadline to apply: March 1, 2025

YOUR CHILD

First name*

Last name*

Date of birth*

Gender*

Female

Male

PARENTS

Parent 1 first name*

Parent 1 last name*

Parent 2 first name

Parent 2 last name

Parent email*

Parent phone number*

Phone

ADDRESS

Street address*

Apt number

City*

State*

Select

Zip code*

Attending parent*

Parent 1

Parent 2

Both

Other primary caregiver(s)

Other primary caregiver(s) attending

Other language spoken*

Spanish interpreter*

Select

HEARING LOSS

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 state*

Select

Please describe your child's hearing

Right Ear

Right ear type of loss*

Sensorineural

Conductive

Mixed

Not applicable/ unsure

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 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

SIBLINGS

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

Yes

Maybe

How many other siblings will participate?*

Select

Number of other siblings participating (other)*

Sibling 1 last name*

Sibling 1 first name

Sibling 1 age*

Sibling 2 last name*

Sibling 2 first name

Sibling 2 age*

Sibling 3 last name*

Sibling 3 first name

Sibling 3 age*

Please list the siblings names and ages, separated by a comma.*

SERVICE PROVIDERS WORKING WITH YOU AND YOUR CHILD

Audiologist last name*

Audiologist first name

Audiologist institution*

Audiologist email

Audiologist phone number

Phone

Teacher/ DHH professional last name*

Teacher/ DHH professional first name

Teacher/ DHH professional center

Teacher/ DHH professional email

Teacher/ DHH professional phone number

Phone

Teacher/ DHH professional minutes per week

Teacher/ DHH professional service method

Listening & Spoken Language

Sign + Speech

Sign Language

Speech-language pathologist last name

Speech-language pathologist first name

Speech-language pathologist center

Speech-language pathologist email

Speech-language pathologist phone number

Phone

Speech-language pathologist minutes per week

Speech-language pathologist service method

Listening & Spoken Language

Sign Language

Sign + Speech

Other professional last name

Other professional first name

Other professional center

Other professional email

Other professional phone number

Phone

Other professional minutes per week

Other professional service method

Listening & Spoken Language

Sign Language

Sign + Speech

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

Number of people in household*

YOUR ACCOMODATIONS

A 30% discount is available to families who elect to commute to the conference daily (arrange your own housing rather than staying at the Stanford student residence onsite). If your family is selected to attend, would you prefer to commute or stay onsite?

Your accommodation preferences

Commute (Arrange Own Housing)

Stay Onsite (Stanford Student Residence)

ALLERGY INFORMATION

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

(select as many as needed)

Select or enter value

Allergic to:

EMERGENCY CONTACT

Emergency contact: first name*

Emergency contact: last name*

Emergency contact: phone number*

Phone

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 last name

Authorized audiologist first name

Authorized child's school name

Authorized specific institutions

Please list names of specific institutions with whom we may communicate regarding your child. (E. g., “Stanford Children’s Hearing Center, Laurel Elementary School, etc…)

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*

To complete the registration, you will be redirected to the Eventbrite for payment.

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

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