obtain a receiver, you may submit the data below:
of Kin or Secondary Contact (residing at a different
Guide Format Desired:
of Receiver Desired:
portable (requires batteries)
Orders are filled as available.
you listen to WXXI on
91.5 Rochester or
you live outside Rochester, do you have cable access?
you registered with:
A. The NYS Commission for the Visually Handicapped?
B. The Library of Congress Talking Books Program?
of Disability: * If you answered NO to both A
& B, please print the
certification form and have it completed by a physician,
nurse, social worker, rehabilitation counselor or other
qualified individual. If you answered YES to either A
or B, completion of the certification is optional. However,
this information is helpful to us to serve you better.
READ THIS AGREEMENT:
I have personally requested this service and authorize
that this application be signed on my behalf (if necessary).
I authorize the release by any agency, organization, doctor
or clinic of medical data needed to determine my eligibility
for the radio reading service. I am aware that the receiver
is on LOAN to me and shall remain the property of WXXI
REACHOUT RADIO. In the event that I no longer need the
service, I will return the receiver to WXXI REACHOUT RADIO
at the address above.
authorize, please type your full name and today's date