Fields marked with an * are required
Applicants must be a legal U. S. citizen/South Carolina. Only completed applications will be considered.
Information that you provide will be kept strictly confidential. If this application is selected for assistance, the resulting transaction and any claim or dispute arising out of such transaction shall be governed by the laws of the state of South Carolina.
TO BE COMPLETED BY APPLICANT OR PARENT/GUARDIAN OF APPLICANT
Information that you provide will be kept strictly confidential.
Names and Ages of Dependents and/or Siblings of applicant. Please indicate by using a “D” or “S” after name):
Note:Implant surgery and hearing aids require a full completed application.
If applying for other equipment and services, please provide a cost associated with request on vendor's letterhead with your submission.
By submitting an abbreviated application, I agree to all terms and conditions in the following sections of the application.
I have read and understand these sections.
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EDUCATIONAL HISTORY (if applicant is a minor)
Please list all support services contacts where applicable:
APPLICANT’S PERSONAL STATEMENT
RELEASE & VERIFICATION OF INFORMATION/UNDERSTANDING OF TERMS
I understand that all the information submitted to The Joyful Noise Foundation within this application is subject to verification by TJNF or their agents. I also understand that if the information I submit is found to be false, such a determination will result in elimination of my name from consideration for assistance.
I further understand that, if I am approved for The Joyful Noise Foundation assistance, there may be other incidental expenses that arise that are not covered under this assistance program and that I will be responsible for these expenses.
I also acknowledge that the Foundation is merely providing service and equipment assistance in connection with the provision of the equipment and services requested herein and shall have no liability of any nature whatsoever in connection therewith, and I hereby waive any claims against The Joyful Noise Foundation in connection therewith.
For consideration received, I do hereby grant to The Joyful Noise Foundation and its founder, directors, officers, agents, representatives, successors and assigns, the absolute and irrevocable right and unrestricted permission, for any purpose whatsoever and without further notice to me or any other further consent or authorization from me to use, reproduce, broadcast, telecast, announce, publish, present and display my name, likeness, features, voice, manual language expressions, identity, resemblance, quotations or photographs, whether alone or in combination, and whether contained or depicted in any photographs, pictures, video, television, digital motion and other electronic media images or other recorded materials of me or in which I may be included with others, either still or moving, live or delayed, or otherwise including any written quotes of information that I readily shared with interviewers; and to copyright same and use individually or in any and all media now and in the future for illustration, promotion, art, editorial, advertising and trade or any other purpose and to use my name in conjunction with the above.
I agree that I am entitled to no compensation for any such use of my name, likeness, features, voice, identity resemblance, quotations or photographs other than what may have already been given to me.
I assign to The Joyful Noise Foundation all rights, title and interest that I may have in the above referenced materials and waive all claim and title thereto and therefore. And I do hereby release the foundation, its respective founder, directors, officers, agents, representatives, successors and assigns, including the person who took or produced the above referenced materials, now and forever, from any actions, suits, claims, covenants, damages executions, demands and liabilities which I or my heirs, representatives, successors and assigns ever had, now have or may have arising out of the aforesaid authorization and consent, without limitation, including any claims for libel or alleged misrepresentation of me by virtue of alterations, visual or audio manipulation or faulty mechanical reproduction.
AUTHORIZATION TO RELEASE/REQUEST RECORDS/INFORMATION
I authorize The Joyful Noise Foundation 501(C)3 to release/request records/information to/from
the following as it pertains to my request to obtain assistance via The Joyful Noise Foundation assistance Et Program.
My signature releases The Joyful Noise Foundation to view and process all confidential medical, personal and financial information, after which time such information will then be retained or destroyed according to
Hospital/Surgical Center & Name of Contact Person (if different from team coordinator):
REQUIRED ATTACHMENTS (Photocopies are permitted)
- Proof of permanent, Legal US residence/South Carolina
- Birth Certificate or US Passport or Certificate of naturalization
- Summary of Costs
- Complete list and statements from implant center or service provider of all costs associated with procedure for which the applicant will be responsible. ( including pre and post surgical services, e. g. evaluations, audiology meetings, speech therapy sessions )
Please ensure that all copies of required documents are sent with original application – please keep a copy of all submitted documents for your own records.
Applicant must return the completed application and all required attachments to The Joyful Noise Foundation, 4611 Hard Scrabble Rd., Suite 216, Columbia S. C. 29229. Phone 803-850-0049
Incomplete applications will not be considered.
Applicants will be contacted if incomplete applications are received and will be given a maximum of 3
months in which to submit all required documents. Failure to provide all materials within 3 months will result in the application being classified as inactive and discarded.
If an applicant later wishes to be reinstated for consideration, all paperwork must be re-submitted under the guidelines in place at that time. Applications are reviewed every 3 months and may be updated and reviewed more frequently as needed.