Application for Free Library Services

Name

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Phone

Email

Date of Birth

Alternate Contact (in case you cannot be reached)

First Last

Alternate Contact Phone

Check here if you have been honorably discharged from the United States military

Yes, I was honorably discharged

Please indicate the primary disability preventing you from reading standard print:

Blindness: Visual acuity of 20/200 or less in the better eye with correcting lens, or the widest diameter of visual field subtending an angular distance no greater than 20 degrees.

Visual Impairment: Inability to read standard printed materials without special aids or devices other than regular glasses.

Physical Impairment: Inability to read or use standard printed materials as a result of physical limitations, e.g. paralysis, missing extremities, extreme weakness.

Reading/Learning Disability: Organic dysfunction of sufficient severity so as to prevent reading printed material in a normal manner.

Moderate Hearing Impairment

Profound Hearing Impairment

Which library service are you interested in?

Downloading Audiobooks and Magazines to Your Smartphone, Computer or Mobile Device (BARD)

Books-on-Demand through the Mail

Books and Magazines in Braille

Telephone Reader Program (TRP)

I do not wish to receive books that contain (check all that apply):

Strong language

Violence

Explicit descriptions of sex

Please indicate the subjects you wish to receive:

Indicate "Other" subject:

I would like to receive books in:

English

Spanish

Other

Indicate "Other" language:

How did you learn about the service?

Braille Institute Staff

Health Care Professional

Other

Indicate "Other" professional:

Are you interested in receiving information about other Braille Institute programs and services?

Yes

No

The following must be completed by a competent certifying authority (e.g., doctor, nurse, teacher, librarian, counselors, social workers):

Name of Certifying Authority

First Last

Title and Occupation

Name of Facility/Organization/Office

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

Certify(Required)

I certify that the applicant named is unable to read or use standard printed material for reason(s) indicated above.

Signature(Required)

Playback equipment and special attachments are supplied to eligible readers on extended loan. If this equipment is not being used in conjunction with recorded reading materials provided by the Braille Institute Library, it must be returned to the issuing agency. All patron records pertaining to this service will remain confidential.

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Application for Free Library Services

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