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Nominate someone you know to receive the Gift of Hearing

Nominator Information

Complete this section with your information when you’re the one doing the nominating.

Be advised: People can be nominated only once in their lifetime. If they are selected for Gift of Hearing support, this is a one-time support for hearing aids and services.

Name(Required)

First Last

Organization

(if applicable)

Email(Required)

Address(Required)

Street Address Address Line 2 City Province Postal Code

Phone (Home)

Phone (Cell)

Relationship to the person you are nominating(Required)

Does the person know you are nominating them?(Required)

Yes

You understand all nominees will be considered however a limited number of nominees will receive the free hearing aids and service. You also understand the decision of the review panel is impartial and final.(Required)

Yes

Nominee Information

Complete this section with information about the person you are nominating.

Name(Required)

First Last

Email(Required)

Address(Required)

Street Address Address Line 2 City Province Postal Code

Phone (Home)

Phone (Cell)

Is this person over 19 years of age?(Required)

Yes

Why do you think they need hearing aids?(Required)

Why do you think they need to receive the free hearing aids? What are their circumstances that require this kind of support?(Required)

What difference will hearing aids make to this person’s life?(Required)

How active in their community is this person?(Required)

Is the nominee still employed? If yes, what is their line of work?

Terms & conditions(Required)

I have read and accept the terms of conditions of eligibility as nominator. I understand any conditions that need to be met by the nominee will be reviewed with the nominee if they are selected to the short list and I have no responsibility for the nominee meeting the terms and conditions.

No purchase is necessary to nominate and no purchase will be required by the selected recipients of the free hearing aids and service.
Hear Well Be Well takes no responsibility for lost, misplaced or stolen nomination forms.
Nominee must be over 19 years of age.
Nominee must be resident of Ontario.
If nominee already has hearing aids, they must be more than seven (7) years old.
Nominee must be able to attend one of the Hear Well Be Well locations, in person, for hearing assessment. Check the Hear Well Be Well website for a list of locations.
Selected nominees will be screened according to the information completed on the Nominee Form and on the results of the hearing assessment.
The free hearing aid and service awarded to the recipients cannot be exchanged for cash.
To become a recipient of the free hearing aid and service:
1. Nominee must be 19 years of age or older and be a resident of Ontario.
2. Nominee must medically require hearing aids based on the comprehensive hearing assessment completed at a Hear Well Be Well location. Check the Hear Well Be Well website for a list of locations.
3. Nominee must not have hearing aids that are less than seven (7) years old.
4. Nominee must agree to attend all follow-up appointments to ensure they are adapting to and caring for their hearing aids as prescribed.
5. Nominee must agree to have their photograph taken and sign a release allowing Hear Well Be Well to share their 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.
Hear Well Be Well reserves the right, at its sole discretion, to disqualify any individual who tampers or attempts to tamper with the nomination process, the operation of the Program, the Program website page, violates these Terms and Conditions, or acts with any intent to annoy, abuse, threaten or harass any person involved in the Program.
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

Nominate someone you know to receive the Gift of Hearing

Nominator Information

Nominee Information

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