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Application to receive the Gift of Hearing

To apply to Gift of Hearing for yourself, you must complete this form for the selection committee’s review. Review can take up to 10 business days. You will be contacted after the review to let you know if you will move forward in the Gift of Hearing process.

You can only apply for Gift of Hearing once in your lifetime. Gift of Hearing is one-time support for free hearing aids and services. Gift of Hearing is non-transferable. If it’s found that your hearing loss cannot be corrected with hearing aids, you cannot offer your spot in the program to another person.

Ensure you read the terms and conditions and provide all information requested on the form.

Name(Required)

First Last

Email(Required)

Address(Required)

Street Address Address Line 2 City Province Postal Code

Phone (Home)

Phone (Cell)

Are you the sole source of income in your home?(Required)

Yes

Sources of Household income:(Required)

Employment

Disability

CPP/OAS/GIS

Pension

Investments

Other

Other source of Household income

Do you work or volunteer outside your home?(Required)

Yes

What is/was your line of work?(Required)

Have you had your hearing tested?(Required)

Yes

Where was your hearing tested?

Why do you need Gift of Hearing support?(Required)

How will Gift of Hearing change your life?(Required)

Terms & conditions(Required)

I have read and accept the terms of conditions of eligibility. I understand the review process includes me meeting the outlined conditions and my application will be reviewed by the impartial selection committee.

No purchase will be required by the selected nominee or applicant for the free hearing aids and service.
You can apply for Gift of Hearing only once.
You must be over 19 years of age.
You must be resident of Ontario.
You must be willing and able to attend one of the Hear Well Be Well locations, in person, for hearing assessment. Visit our website at HearWellBeWell.ca to find our locations.
You will be screened according to the information completed on the Application Form and on the results of the hearing assessment.
Any free hearing aid and service awarded cannot be exchanged for cash.
To become a recipient of the free hearing aid and service:
1. You must medically require hearing aids based on the comprehensive hearing assessment completed at a Hear Well Be Well location. Visit our website at HearWellBeWell.ca for a list of our locations.
2. You must not have hearing aids that are less than seven (7) years old.
3. You must agree to attend all follow-up appointments to ensure you are adapting to and caring for your hearing aids as prescribed.
4. You must agree to have your photograph taken and sign a release allowing Hear Well Be Well to share your hearing story in appropriate marketing and education materials pertaining to the charitable work done by the organization.
Hear Well Be Well reserves the right to terminate, suspend or modify this Program, in whole or in part, at any time and without notice or obligation, if, in Hear Well Be Well’s sole discretion, any factor or event arises that could interfere with the proper conduct, administration, security or impartiality of the Program as outlined in these Terms and Conditions. Without limiting the generality of the foregoing, if the Program, or any part of it, is not capable of running as planned for reason, including, but not limited to, infection by computer virus, tampering, unauthorized intervention, fraud, programming errors or technical failures, which corrupt or affect the administration, security, fairness, integrity or proper conduct of this Program, Hear Well Be Well may, in its sole discretion, void any suspect nominations and:
- Terminate the Program, or any portion of it;
- Modify or suspend the Program, or any portion of it, to address the impairment and then resume the Program, or the relevant portion, in a manner that best conforms to the spirit of these Terms and Conditions.
Limitation of Liability By participating in this Program, nominators, nominees, finalists and recipients agree Hear Well Be Well and its authorized agents have no liability whatsoever for, and shall be held harmless against any liability for injuries, losses or damages of any kind (including direct, indirect, incidental, consequential or punitive damages) to persons or property resulting from the Program, including the acceptance, possession, use or misuse of the hearing aids.
Protection of Personal Information Unless otherwise authorized, any personal information provided by the nominator, nominee, finalist or recipient when they participate in the Program, will be used only for the administration of the Program however all parties may give their express, opt-in consent to receive electronic messages from Hear Well Be Well. All personal information Hear Well Be Well or its authorized agents collect will be handled in accordance with the Hear Well Be Well privacy policy which may be found at: Privacy Policy – Hear Well Be Well | Life Sounds Good

Consent(Required)

If selected, I agree to attend all appointments required by Hear Well Be Well to best serve my hearing health and proper use and care of hearing aids.

Consent(Required)

I agree that all the information I have provided is accurate to the best of my knowledge and any errors or misleading information may disqualify me from being selected.

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I would highly recommend!

I was recommended to visit the office in Mount Forest after I told a friend that I was having hearing issues for the last month. He said they would do a hearing test and clean my ears if it was needed. I made the appointment and saw Chantel a week later. I couldn't get over how professional Chantel was and how much detailed she went into to explain the process verbally and with visual aids. I was pleased with the outcome of having normal hearing and that the problem was just a wax buildup. I would highly recommend this location as both Chantel was extremely helpful and Melissa at the front desk was very friendly. Thank you for your services.

Cathy Broughton

Mount Forest Hearing Clinic

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Name(Required)

First Last

Email(Required)

Address

Street Address Address Line 2 City Province Postal Code

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