Receiver Application

Reachout Radio
280 State Street
P.O. Box 30021
Rochester, NY 14603-3021

To obtain a receiver, you may submit the data below:

Prefix *

Full Name *

Date of Birth *

Street Address *

City *

State *

ZIP *

County *

Example: (Monroe, Livingston, etc)

Is this a multi-resident facility? *

No

Yes (If so, which?)

If you selected Yes above, please provide the facility name.

Home Telephone

Work Telephone

E-Mail *

Occupation

Next of Kin or Secondary Contact (residing at different address):

Full Name *

Next of Kin or Secondary Contact's Relationship to you *

Spouse

Parent

Child

Other

If you selected "other" above, please specify the Next of Kin (or Secondary Contact's) relationship to you.

Street Address *

City *

State *

ZIP *

Telephone *

E-Mail

Program Guide Format Desired *

Large Print

Audio CD

Braille

E-Mail

WXXI Reachout Radio is available as a stream on the internet or via closed-circuit SCA radio receivers. The internet stream requires listeners to have internet service and an internet-ready device, internet radio or computer. Once a listener registers for access to this stream, the internet provides clear 24-hour access to the service.

The closed-circuit SCA radios are available free of charge and come in a table top or portable (requires batteries) model. (NOTE: Clarity of reception on the closed-circuit radios is quite variable depending upon location.)

Type of Service Access preferred:

Table top SCA radio

Portable SCA radio

Internet stream (Provide E-Mail address below for authorization)

If you selected Internet stream above, please enter an E-Mail address for authorization and to receive further information.

Orders are filled as available.

Do you listen to WXXI on

91.5 Rochester

90.3 Houghton

Are you registered with:

A. The NYS Commission for the Visually Handicapped?

Yes

No *

B. The Library of Congress Talking Books Program?

Yes

No *

Required Certification 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.

Please explain the nature of the disability which qualifies this individual as print handicapped (the inability to access standard print information due to vision loss, physical disability, temporary condition, or the inability to hold or comprehend the printed word.)

If you selected "other" please specify the visual impairment here.

Physical Impairment:

Hard of hearing (some radio models are equipped with a headphone jack - headphones are not provided)

Other (please specify below)

If you selected "other" please specify the physical impairment here.

PLEASE 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.

I agree to return the SCA radio receiver to WXXI Reachout Radio when it is no longer needed.

To authorize, please type your Initials below: *

Attachment	Size
2018_recert_rr.pdf	45.47 KB

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