Most
of this page's content provided by the Valley Voice reading service ; material
about Valley Voice Friends activities (if any) will be shown within gold
boxes.
Most
of this page's content provided by the Valley Voice reading service; material
about Valley Voice Friends activities (if any) will be shown within gold
boxes.
Application
for Valley Voice's Service
NOTE : FORM CANNOT BE SUBMITTED ONLINE, SO PRINT OUT BLANK FORM OR TYPE ONLINE AND THEN PRINT OUT ---USE "LANDSCAPE" PRINTER SETTING.
The Valley Voice is a reading service for the blind and print-impaired, giving medically-eligible listeners access to local and
national newspapers and journals. Specialized radio receivers are lent
free of charge (to medically-qualified people without access to Valley Voice via Cable TV) for as long as the listener needs or wants the service.
Listeners are not required to pay for the Valley Voice services, although
donations are appreciated. Valley Voice receiver units are the property
of the Valley Voice and MUST be returned if ever services are no longer
needed or wanted.
Name:
Address:
Line 2:
City/St/Zip:
E-mail:
Home Phone:
Day Phone:
Your Cable Company:
Optional Information.
Birthdate:
Occupation:
Hobbies/Interests:
How did you hear of the Valley Voice?
REQUIRED.
Name & Address of Closest Relative/Friend
OR of Person Filling Out this Form:
Name:
Address:
Line 2:
City/St/Zip:
E-mail:
Home Phone:
Day Phone:
Relationship to applicant:
Applicant's condition(s) include: (check all that apply) Partial
vision loss.
Total vision
loss.
Impaired ability
to focus the eye.
Impaired ability
to grip printed matter or hold it steady.
Impaired
ability to hold the head steady.
Other --as
described below:
You must arrange for a "third party" professional (not a member of the applicant's family) to certify that the applicant DOES have a print-impairment. Ask the person to CONTACT the Valley Voice and confirm that the applicant is print-impaired. Certfication DOES NOT require a doctor's signature. Any health care worker (including a doctor or nurse), retirement home administrator, social worker, or clergyperson (minister, rabbi, priest) will may certify here. Certifying professional's name, title, and organization and address:
Name:
Title:
Address:
Line 2:
City/St/Zip:
E-mail:
Home Phone:
Day Phone:
I will send someone to the Valley Voice pick up the receiver
I want the Valley Voice to send someone to deliver the receiver to me.
Directions to my
Residence
or
Delivery Site:
In submitting this form I hereby agree to the terms and conditions stated on this application. I WILL ARRANGE FOR THE RETURN OF the equipment if ever services are no longer needed or wanted. I ALSO CERTIFY that the person named in the APPLICANT box, above, DOES
HAVE A CONDITION WHICH IMPAIRS THE ABILITY TO SEE OR HOLD PRINTED MATTER.
