Self Nominate

Your Name *

First Name

Last Name

Your Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Emergency Contact Information *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Employer Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer Phone

(###)

###

####

Have you ever had hearing devices before? *

Yes

No

Have you had a hearing test in the last 6 months? (if it was not with bow river hearing please email to brooke@bowriverhearing.com) *

Yes

No

If yes, are your hearing devices less than 5 years old?

Yes

No

Does a hearing problem cause you difficulties at work? *

Yes

No

N/A

Does a hearing problem impair you from obtaining a job? *

Yes

No

N/A

Does hearing problem impair you from doing your job well? *

Yes

No

N/A

Does a hearing problem cause you to feel embarrassed when you meet new people? *

Yes

No

N/A

Does a hearing problem cause you to feel frustrated when talking to members of your family? *

Yes

No

N/A

Does a hearing problem cause you difficulty when visiting friends, relatives or neighbors? *

Yes

No

N/A

Does a hearing problem cause you to attend events less often than you would like? *

Yes

No

N/A

Does a hearing problem cause you to have arguments with family members or friends? *

Yes

No

N/A

Does a hearing problem cause you difficulty when listening to TV or Radio? *

Yes

No

N/A

Consent to be recorded / filmed: Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to [legal entity/organization], its affiliates and agents, to use my image and likeness and/or any interview statements from me in its publications, advertising or other media activities (including the Internet). This consent includes, but is not limited to: (a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice; (b) Permission to use my name; and (c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), in theatrical media and/or in mailings for educational and awareness. *

Yes

No