2016 Convention Family Scholarship APPLICATION

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2016 CONVENTION FAMILY SCHOLARSHIP PROGRAM Application Packet OVERVIEW AG Bell recognizes that families with a child who is deaf or hard of hearing may have…
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2016 CONVENTION FAMILY SCHOLARSHIP PROGRAM Application Packet OVERVIEW AG Bell recognizes that families with a child who is deaf or hard of hearing may have significant financial pressures. AG Bell is offering the Convention Family Scholarship Program for deserving families who have never attended an AG Bell Convention to learn new information and network with professionals and other families. Families awarded a scholarship will receive:  Full Convention registration for two adult family members.  Up to two registrations for the Children’s Program. This program is for children from infancy through age 14 and offers fun activities throughout the Convention..  One hotel room with two double beds for up to four nights between June 30 and July 3, 2016. The family is responsible for all travel arrangements, long distance and local, as well as food and entertainment outside of what is provided through the convention registration. ELIGIBILITY CRITERIA In order to be eligible for this program, applicants must meet all of the following criteria:  At least one child under the age of 18 must have a bilateral hearing loss or bilateral Auditory Neuropathy diagnosed prior to the child’s fourth birthday (pre-lingual). Note: Children with unilateral (one-sided) hearing loss or unilateral auditory neuropathy do not qualify.  The child’s hearing loss must be in the moderately severe to profound range. This means that applicants must have an unaided Pure-Tone Average (PTA) of 55dB or greater in the better hearing ear in the speech frequencies of 500, 1000, 2000 and 4,000 Hz.* Children with cochlear implants meet this eligibility requirement. *This may not apply for children who have been diagnosed with Auditory Neuropathy. For information on required documentation for AN, please see the “documentation” section on the next page. Formula for calculating the PTA: On the unaided audiogram, look at the results for the better hearing ear at 500, 1000, 2000 and 4,000 Hz and add those four numbers together, then divide that total by four. The result is the Pure Tone Average. To be eligible for this award, the child’s PTA must be 55 or greater.  Listening and Spoken Language must be the child’s primary mode of communication.  Families must be first-time attendees for an AG Bell Convention.  Parents/guardians should be able to clearly describe their need for financial assistance and how an award would help their child/family. AG Bell membership is not required; however, preference is given to AG Bell members. APPLICATION DEADLINE The deadline for applications is March 18, 2016. All materials MUST ARRIVE together in one package at the address below by 5:00 p.m. EST on March 18, 2016. Families are en courage to apply before the deadline. No supporting materials will be accepted separately from the application. Send application package to: AG Bell - Convention Family Scholarship 3417 Volta Place NW Washington, DC 20007  Due to the number of applications we cannot confirm receipt of applications. You may choose to send your application using a service that can confirm delivery (such as USPS Express Mail, FedEx, UPS, etc.) , but please do not require a signature as this can delay delivery. AG Bell does not accept responsibility nor make exceptions for any delays or delivery errors on the part of delivery services including delays due to the requirement of a signature. To ensure timely delivery, applicants are encouraged to submit applications well in advance of the deadline.  Faxed applications are not accepted under any circumstances.  Late and incomplete applications are not considered under any circumstances.  Applications are not returned for any reason. Please do not contact AG Bell seeking an exception to these policies. NOTIFICATION By April 15, 2016, families will be notified whether or not they were selected to receive a family scholarship; notifications will be made by email only. Families who are not selected to receive a Convention Family Scholarship will be guaranteed the Early Bird rate for registration until May 1, 2016. APPLICATION SUBMISSION INSTRUCTIONS  All pages of the application and supporting materials must be on 8½” x 11” paper.  The application and supporting materials must be in English.  All pages must be single-sided.  Be sure these items are included:  Application – Each section of the application must be completed and the application must be signed.  Parent Essay  Documentation of hearing loss.  For children who use hearing aids, an unaided audiogram performed within the last 12 months.  For children with a cochlear implant, please include the most recent programming report. If your child uses a cochlear implant and a hearing aid, only a CI programming report is required. Please do not include an audiogram in lieu of a programming report.  For infants, toddlers and young children who have been diagnosed with Auditory Neuropathy and do not have a cochlear implant, please include an unaided audiogram performed within the last 12 months and a report from the audiologist diagnosing AN with recommendations. If an audiogram is not available, please include a copy of the ABR and the OAE (if available) along with the report from the audiologist with the AN diagnosis and recommendations.  For children age 6 and older who have been diagnosed with Auditory Neuropathy and who do not have a cochlear implant, please include the last two unaided audiograms (one must have been performed within the last 12 months) along with the report from the audiologist with the original AN diagnosis. If two audiograms are not available, please include a recent report from the audiologist with the current status of the AN along with recommendations.  A letter of recommendation from a current AG Bell member or from your local AG Bell Chapter. If you do not know an AG Bell member or if there is no Chapter in your state, then you may provide a letter of recommendation from a hearing health or educational professional (your child’s teacher, early interventionist, speech-language pathologist or audiologist). The letter should be limited to two single-side pages and must be signed.  A letter of recommendation from a non-relative who is familiar with the family’s financial need (maximum of two single-sided pages). NOTE: Two letters of recommendation from two different individuals are required for your application to be considered. Please do not include any additional information, such as tax returns; we cannot consider these items with your application. Applicants are encouraged to keep a copy of their application. Applications will not be returned for any reason. QUESTIONS If you have questions about the program or the application, please contact us by email at info@agbell.org. 2016 CONVENTION FAMILY SCHOLARSHIP APPLICATION IDENTIFYING INFORMATION (Please print clearly or type) Primary Contact (Parent/Legal Guardian): ___________________________________________________ Complete Mailing Address: _______________________________________________________________ _____________________________________________________________________________________ Email Address*: _______________________________________________________________________ *Communication throughout the process will be conducted only via email. If you do not provide an email address, if it’s incorrect, or if we are not able to read it, we will not be able to communicate with you. Your Relationship to the child: Father Mother Legal Guardian Child’s Name: ________________________________________________________________________ Child’s Date of Birth: ___________________ Age: ________ Child’s Gender:  Male  Female (month/day/year) Child’s age when hearing loss was diagnosed: ______________ Age at which he or she was fitted with hearing aid(s): _________________________________________ Does the child have a cochlear implant? Yes No If yes, age at which he or she received the cochlear implant: _______________________________ What method(s) of communication is used with your child at home and in therapy? Check all that apply. _____ Spoken Language _____ Sign Language System (ASL, Signed English, Finger Spelling, etc.) _____ Cued Speech _____ Other, please briefly describe: Please tell us where your child receives auditory/speech-language services: Are you a current AG Bell member? Yes No If you are not currently a member of AG Bell, we are offering a free six-month membership to join our community. This membership provides your family access to online and print resources dedicated to educate and support families like yours. Please let us know if you would like to accept this offer: _____ Yes, I accept the free six-month membership in AG Bell _____ No, thank you AG Bell membership is not required; however, preference will be given to AG Bell members. Acceptance of this free membership offer constitutes membership in AG Bell. FINANCIAL INFORMATION Mother/Legal Guardian’s Occupation: ____________________________________________________ Father/Legal Guardian’s Occupation: _____________________________________________________ Total number of dependents in your household: ________ Does the applicant receive support from Medicaid or SSI? Yes No Please check your total annual gross household range of income: _____ $17,000 or less _____ $17,001 – $34,749 _____ $34,750 – $44,999 _____ $45,000 – $59,999 _____ $60,000 – $79,999 _____ $80,000 – $99,999 _____ $100,000+ PARENT/GUARDIAN ESSAY In your own words, please tell us about your family/your child or children, the methods of communication used regularly in your home and, if applicable, in your child’s educational setting, the progress your child is making in his or her activities (therapy, pre-school, school, etc.), why you’d like to attend the AG Bell 2016 Biennial Convention, and about your financial situation including any unusual circumstances. Your essay may be hand written clearly or typed, but please limit it to two single-sided pages. LETTERS OF RECOMMENDATION Two letters of recommendation are required for all applications. 1. A letter of recommendation from a current AG Bell member or your local AG Bell Chapter. If you do not know an AG Bell member or there is no Chapter in your state, then you may provide a letter of recommendation from a hearing health or educational professional, such as your child’s teacher, early interventionist, speech-language pathologist or audiologist. The letter should be limited to two single-side pages and must be signed. 2. A letter of recommendation from a non-relative who is familiar with the family’s financial need. The letter should be limited to two single-sided pages. AGREEMENT I certify that I am the parent or legal guardian of ____________________________, and that I have included all of the required documents in our application. To the best of my knowledge, all information contained in this application is true and accurate. I understand that if my family is selected to receive an award, AG Bell may release information stating this fact to the media and/or to AG Bell constituents. I further certify that I have read and agree to the terms and conditions of the Family Scholarship Program. Parent/Legal Guardian Signature: ___________________________________________________ Date: _________________________________________________________________________ 2016 CONVENTION FAMILY SCHOLARSHIP PROGRAM SCHOLARSHIP RECOMMENDATION REQUEST You are receiving this recommendation form on the behalf of __________________________ who is applying for a scholarship for the 2016 AG Bell Convention Family Scholarship Program. AG Bell recognizes that families with a child who is deaf or hard of hearing often have extra financial pressures. We are pleased to offer the Family Scholarship Program for deserving families who have never attended an AG Bell Convention to access information and network with other families. In a letter – a maximum of two single-sided pages – preferably on your business or personal letterhead, please answer the following questions:  What is your relationship to the family and how long have you known them?  To the best of your ability, describe the family’s method(s) of communication with their child in daily conversations and/or educational setting (i.e. listening and spoken language, American Sign Language/fingerspelling, total communication, use of interpreters).  Tell us what you know about the therapeutic and/or educational progress of the child.  Other observations or thoughts you have about the family.  Tell us why you believe this family should be considered for a Convention Family Scholarship, including any extenuating circumstances this family may be experiencing. Your recommendation is required for the family’s application to be complete.
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