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APPLICANT MUST BE A U.S. OR CANADIAN CITIZEN

Only complete applications will be considered for assistance. We request that all recipients pay for shipping and handling.


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 Illinois. If you have already been awarded, or have sought cochlear implant equipment from another organization (such as the CNI), and are applying for financial assistance for surgical, hospital, or other CI related fees only, please do not apply.

CIAF accepts applications for equipment assistance only. CIAF provides NO monetary assistance whatsoever nor any funding for cochlear implant surgery. All requests for equipment must be verified by the patient’s doctor or audiologist. Processors and most equipment will be sent directly to the patient’s CI center for programming.

If approved, you will be notified of the total shipping cost before we send out any equipment. A PayPal invoice will be sent and equipment will ship as soon as the invoice is paid.


Application for Cochlear Corporation

CIAF is a 501(c)(3) non-profit organization which relies primarily on donations to help us to provide cochlear implant equipment to qualified applicants without cost to the family or individual in need. As part of our program, we require applicants to complete a personal statement as to how the cochlear implant will improve their life. We also require a photo of each applicant to accompany his/her application. While the personal statement gives a voice to our mission, photographs provide a visual connection for our supporters and helps bring an applicant’s story to life. Both components greatly assist us in promoting our mission to help more people hear! If the applicant is between 13 and 18 years of age, both the applicant and a guardian should write separate statements. If the applicant is less then 13 years of age, a statement from a guardian is sufficient.

I authorize the Cochlear Implant Awareness Foundation, hereafter referred to as “CIAF” to publish photographs of me, and my name and likeness, for the use in CIAF print and online marketing materials as well as other CIAF publications. I hereby release and hold harmless CIAF from any reasonable expectation of privacy or confidentiality associated with images specified above. I further acknowledge that my participation is voluntary and that I will not receive financial compensation of any type associated with the taking or publication of these photographs or participation in company marketing materials or other CIAF publications. I acknowledge and agree that publication of said photos confers no rights of ownership or royalties whatsoever. I hereby release CIAF, its contractors, its employees, and any third parties involved in the creation or publication of marketing materials, from liability for any claims by me or any third party in connection with my participation.