Listen to Me! Hawaii Family Application

We are excited to join local Hawaii professionals in launching Listen to Me! Hawaii— a comprehensive training for families receiving cochlear implants for their young children. This program will be modeled after our current California program, the Listen to Me! Conference at Stanford University.


Listen to Me! is a research-based, family centered, supportive training program that we have created and improved upon for the last 13 years. We are looking for opportunities to share this model at a larger scale, and Hawaii is our first adventure! In order to start a program that will be sustainable and repeatable annually in Hawaii, we are collaborating with many local medical professionals and educators in Hawaii to host our first LTM Hawaii Conference in 2022.


We have assembled an LTM Hawaii Leadership Team, and we are thrilled to be working closely with these four amazing specialists in Hawaii to build our program:


Jennifer Clark, MA, Early Childhood D/HH Specialist

Christy Chadwick, M.A. MFT, M.S.D.E.

Kimi Perez, MS, CCC-SLP, LSLS Cert AVT

Lori Wiley, AuD, PhD, CCC-A, Audiologist


The LTM Hawaii Conference will be comprised of 3 in-person days and 2 virtual days. The in-person days will be November 11—13, 2022.


The curriculum, content, and structure will predominantly be the same as the LTM California Conference, while also including customized content for families living in Hawaii.


Who is eligible?


Child must be between 0 and 5 years old (must turn 6 after November 15).

Child must have hearing loss and use hearing technology to access sound. Priority will be given to children who use cochlear implants (CIs) or are under consideration for CIs by a CI center.

Family must reside in Hawaii.

Family (including at least one parent/guardian) must commit to participating in each day of the conference (3 in person days plus 2 virtual days).


You will be redirected to a secure payment platform after you submit this application. You will need to pay $50 DEPOSIT.


If your family is selected to attend "Listen to Me", we will apply the $50 toward your registration fee. If you are not selected, we will refund you the $50 application fee.


Please note that our top priority is to help families who need this most, so DO NOT LET COSTS PROHIBIT YOU FROM APPLYING.


We will work with your family to pay only as much as you are able without it becoming a financial burden to you. 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.

Child

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Parents

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All primary caregivers are invited to attend the program

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Hearing Loss Information

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

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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

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Service providers working with you and your child

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AUTHORIZATION FOR RELEASE OF INFORMATION

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: 7/1/ 2023 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.

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Since your child is under 3, you are eligible for the CSC to pay the $50 application fee (and possibly more financial support to attend the conference, depending on financial need and availability of funds).


In order to access this gift, please click below to register with the CSC, and they will pay this initial $50 fee on your behalf.


Listen to Me Conference Scholarship Request


NOTE: Your registration is not confirmed until you submit this form.

Please complete the Scholarship Request form and then return here to submit.


Eventbrite registration is not required.


You will be redirected to a secure payment platform after you submit this application. You will need to pay $50 DEPOSIT.

If your family is selected to attend "Listen to Me", we will apply the $50 toward your registration fee. If you are not selected, we will refund you the $50 application fee.


Please note that our top priority is to help families who need this most, so DO NOT LET COSTS PROHIBIT YOU FROM APPLYING. We will work with your family to pay only as much as you are able without it becoming a financial burden to you. 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.

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