Thank you for your interest in the Help America Hear Program

Thank you!

The Foundation for Sight & Sound’s Help America Hear Program thanks you for TAKING THE FIRST STEP TOWARDS IMPROVING YOUR QUALITY OF LIFE WITH BETTER HEARING.

After you fill out and submit the below form, within 10 minutes you will receive an email with a link to retrieve the application. Please click on the link and print out the documents.

If you have not received this email after one hour please check your spam/junk folders before contacting us.
You can either email us at info@foundationforsightandsound.org or
call us at631-366-3461.

Title

*First Name

Middle Name

*Last Name

Company

*Address Line 1

Address Line 2

*City

*State

*Zip Code

*E-mail address

*Phone Number

Fax Number

Please take a moment and help us learn about you. Your responses to the following questions are for research only and have no impact on the outcome of of any application submissions.

Who are the Hearing Aids for?
If other please explain:
Age of Applicant:
Your Relationship:
If other please explain:
Age of Person Filling Out this Form:
Gross Household Income of Applicant:

Do you have any Comments or Concerns?

Thank You!
Please be assured Foundation For Sight & Sound does not share or sell any information provided to us.

Get Involved

Thank you!