Giving the Gift of Hearing

Jacob’s Ride provides financial support to help a select number of patients, that either have no health insurance coverage or otherwise cannot afford the cost of surgery, to receive cochlear implants.

Jacob's Ride for Hearing (JRFH) is a volunteer-only organization and has no employees. JRFH is a tax-exempt, charitable organization and is eligible to receive tax-deductible donations under IRS Code 501(c)(3); EIN #85-0932630

Need Financial Assistance?

Requesting financial assistance from Jacob’s Ride is an easy two-step process.

1. Click and read the “ELIGIBILITY CRITERIA”

2. Please fill out the form below and click SUBMIT to request an application.

CI Candidate Name

First Name

Last Name

Name of Person Requesting Application

First Name

Last Name

Phone

If Applicable

(###)

###

####

Relationship to Candidate

Name of Candidates Surgeon

First Name

Last Name

Hospital Affiliation of Surgeon

Name of Candidates Audiologist

First Name

Last Name

Name of Hospital

Hospital City & State

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Brief History of Candidates Hearing Loss Journey

JRFH will email you the application within a few days of your request.

Please do not be intimidated by the actual application form!

General Instructions

1. Be sure to sign/initial the release/permission sheets that will allow us to discuss your case.

2. Printed material should be mailed via USPS (The application, audiological tests, medical insurancepolicy, insurance denials, birth certificates, citizenship or legal residency papers, etc).

3. Scanning documents is acceptable. However, each document must be a separate pdf.