The patient resides in Ada County or Canyon County, Idaho and requests to participate in the Assistance League of Boise, Project Hearing Program. In the event I am signing this release on behalf of another person, I represent that I have power of attorney to do so or I am that person's legal guardian or spouse.

1. I understand that the hearing aid I am applying for may have been donated to Assistance League of Boise for the purpose of providing hearing aids for individuals who may benefit from amplification but are financially unable to purchase a new appliance.
2. I understand that I (or in the event the request to participate is made on behalf of another person) must have a current hearing evaluation (audiogram) approved by a certified audiologist or licensed hearing aid dealer who will also obtain ear mold impressions and perform fitting of hearing aids.
3. I understand that the hearing aid I am receiving is being donated by Assistance League of Boise, and that the appliance is not the property or responsibility of the professional fitting the aid. If for any reason I am no longer using the hearing device(s), I will return the device(s) to Assistance League of Boise.
4. I understand that all professional fees not covered by insurance are paid by Assistance League of Boise.

I hereby release and agree to hold harmless Assistance League of Boise, the county of Ada, the state of Idaho, or any other person associated with the Hearing Aid Loaner Program and their agents, employees, and representatives from any services rendered or products provided in that program, including but not limited to hearing loss, evaluation, diagnosis, treatment, the process of obtaining an ear mold impression, and the fitting of an earmold/hearing aid, and counseling in their use.