Name of Family_____________________________________________________________

 

Address____________________________________________________________________

 

Phone #___________________________________________________________________

 

Names & Ages of Children___________________________________________________

__________________________________________________________________________

 

Name & Age of Child with Hearing Loss_______________________________________

 

School Child is attending_____________________________________________________

                ___Public School                 ____School for the Deaf   ___Other

 

Are you a Grange Member?  ___Yes                              ____No

                If yes include the name and number of the Grange.  You may also include information as to your involvement in the Grange.

 

 

Service needed for the Child with hearing Loss :  Please check all that apply:

___Speech Therapy                            ____Surgery                         ___Hearing Aid(s)

___Other hearing related devices                     ___Other

 

Are you (Child's parents) a citizen of the United States?  ___Yes   ___No

 

If you are not a citizen are you a legal immigrant?____Yes  ___No

 

Include a brief description of the cause of hearing loss if known, previous treatment, needed or expected treatment current and future. (Additional pages may be used if necessary).

 

 

 

 

 

 

 

 

What are your family goals for the child with hearing loss?

 

 

 

 

 

 

Please include the following with this application:

                ____Current expenses connected to child's hearing loss not covered by insurance.

                ____Letter of proof of hearing loss or hearing test results or both.

                ____Picture of child. (may be a family picture)

                ____Letter granting permission for Grange to use story and picture for promotional purposes of the project.

                ____A statement of need both financially and other.  Why are you requesting funding from the Colorado State Grange Mandy Project?  Your financial situation may be a determining factor if many applications are received.  What is your monthly income?

 

 

Send Application to:  Cindy Greer, 7629 C.R. 100, Hesperus, CO  81326

or fax to 970-588-3871.