Application For Funding

The H.I.K.E. (Hearing Improvement Kids Equipment) Fund is a registered non-profit Canadian charity. It was formed in 1990 as the philanthropic project for Job's Daughters International as a way to provide hearing assistive devices for families and children in need. These grants are awarded to registered audiologists or hearing clinics on behalf of the family's application.

Applications must be accompanied by a prescription for a specific hearing devices and its associated cost quote.

As resources are limited, the grant(s) awarded may not meet the total amount requested. If that is the case, and additional funds are required by the applicant to secure the required device, H.I.K.E. funds will only be granted when they are combined with funds from other sources.

CHEQUES ARE ONLY ISSUED TO THE AUDIOLOGIST OR CLINIC SUPPLYING DEVICES.

Applicant Info

Please provide all requested supporting documentation. Your application cannot be processed until we have all the required information.

Child's Name *

Date Of Birth *

Name(s) of Parent / Guardian *

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Home Address

Address Line 1 *

Apartment, Suite, etc.

City *

Postal Code *

Province *

Phone Number *

Email Address *

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Assistive Device

Type of Device Required

Referring Physician / Audiologist *

Physician Contact Information *

Name of Supplier (if different from Physician / Audiologist) *

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Financial Disclosure

Name of Person Completing This Form *

Relationship to Child *

Applicant Address *

Applicant Address Line 1 *

Applicant Address Line 2

City *

Postal Code *

Province *

Phone Number *

Previous Step

Please provide the names of those in the household who are employed and their employer's information.

Number Of People Living At This Address *

Employer Name *

Income From Salary / Wages

Social Assistance

Alimony / Child Support

Rental Income (If Applicable)

Investment Income (If Applicable)

Other Income

Total Monthly Income

Please Attach Your Most Recent Income Tax Slip (T4) *

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Monthly Expenses

Please support expenses with receipts/ bank statements or monthly invoices.

Monthly Rental/Mortgage *

Home/Renter's Insurance

Transportation Expenses *

Utilities *

Phone *

TV / Internet *

Healthcare Expense *

Groceries (Approximate) *

Clothing (Approximate) *

Other Expenses Not Mentioned *

Total Monthly Expenses *

Supporting Documentation For Expenses *

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Explanation of Need

Please include a letter from the parent/guardian fully explaining the financial need and telling us something about the child in need of hearing devices.

Letter of Explanation *

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Supporting Health Documents

Please attach your child's most recent audiogram *

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Please attach the prescription for the hearing devices required as indicated by physician or licensed audiologist *

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Please attach an itemized quotation for the prescribed hearing device and incidental expenses submitted on official letterhead from the referring physician/audiologist that includes contact information. *

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Supporting Health Documents

Thank you for your application, we will review and contact you soon.

There was an error trying to submit your application. Please try again later.

Application Test

Application For Assistance (Test)

Application For Funding

Applicant Info

Home Address

Assistive Device

Financial Disclosure

Monthly Expenses

Explanation of Need

Supporting Health Documents

Supporting Health Documents