Scholarship Request Form

Please tell us about yourself and your family.

First Name

Last Name

Phone

Email

Scholarship type

First time scholarship request

Renewal scholarship request

Child's name

Child's age

Child's hearing difference

Street Address

Street Address Line 2

City

State

Zip code

Please provide a detailed explanation regarding why the annual membership cost would cause hardship for your family:

Thanks for reaching out! We'll be in touch soon.

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