Application for Free Library Service—
Individual
DC Public LibraryFREE MATTER
Adaptive Services, Rm 215FOR THE
901 G Street NWBLIND OR
Washington, DC 20001-4599HANDICAPPED
DC Regional Library for the
Blind and Physically Handicapped
Application for Free Library
Service for Individuals
Adaptive Services DivisionSpecial Numbers for
901 G Street NW, Room 215Hearing Impaired Callers:
Washington, DC 20001Video Relay: 866-570-7364
Video Phone:202-559-5368
Phone: 202-727-2142TTY: 202-727-2145
Thank you for your interest in service from the DC RegionalLibrary for the Blind and Physically Handicapped, a cooperating network library of the National Library Service for the Blind and Physically Handicapped of the Library of Congress (NLS).
The DC Regional Library serves eligible persons who live or work in the District of Columbia. If you are interested in service for someone who lives elsewhere, please call us for contact information for their location. In addition to this Individual Application in English, Individual Applications in Spanish and Applications for Institutional Service are available. Call 202-727-2142 to request one, or with questions.
When this application is complete and certified according to the instructions inside, please return it to the address on the back page.
We look forward to serving you.
DC Regional Library for the
Blind and Physically Handicapped
Application for Free Library
Service for Individuals
Please Print or Type, and complete all information:
Name (Last) (First) (Middle Initial)
Street AddressApt. #
ZIP
Telephone (primary) ()
Telephone (other, if any) ()
Date of BirthGender
E-mail Address
Please give the name of a person to contact if you cannot be reached for an extended period of time. This person must be able to help us locate you.
Name Telephone ()
Students using a school address, please provide parent’s name, address and telephone:
[]Check here if you have been honorably discharged from the Armed Forces of the United States.
Statement of Eligibility of Blind and Other Physically Handicapped Persons for Loan of Library Materials
Please indicate the primarydisability preventing you from reading regular printed material, as defined below. Check only one.
[] Blindness - Persons whose visual acuity, as determined by competent authority, is 20/200 or less in the better eye with correcting lenses, or whose widest diameter of visual field subtends an angular distance no greater than 20 degrees.
[] Visual Handicap - Persons whose visual disability, with correction and regardless of optical measurement, is certified by competent authority as preventing the reading of regular printed material.
[] Deaf-Blind
[] Physical Handicap - Persons certified by competent authority as unable to read or unable to use standard printed material because of physical limitations.
[] Reading Disability - Persons certified by competent authority as having a reading disability resulting from organic dysfunction and of sufficient severity to prevent reading printed material in a conventional manner.
In addition to the qualifying disabilities above, do you also have a hearing impairment? If yes, indicate the degree.
[] Moderate--some difficulty hearing and understanding speech.
[] Profound--cannot hear or understand speech.
Certification of Eligibility for Library Services
Certifying Authority:
In cases of blindness, visual impairment, or physical limitations, “competent authority” includes doctors of medicine; doctors of osteopathy; ophthalmologists; optometrists; registered nurses; therapists; and professional staff of hospitals, institutions, and public or private welfare agencies (e.g., social workers, case workers, counselors, rehabilitation teachers, and superintendents). In the absence of any of these, certification may be made by professional librarians or by any person whose competence under specific circumstances is acceptable to the Library of Congress.
In the case of a reading disability from organic dysfunction, competent authority is defined as doctors of medicine and doctors of osteopathy who may consult with colleagues in associated disciplines.
Family members may not certify applications.
To Be Completed By Certifying Authority: I certify that the named applicant requesting library service is unable to read or use regular printed material for the reason indicated on this form.
Signature Date
Please print or type:
NameTelephone ( )
Title/Occupation
Organization
Address
City State ZIP
Please return this application with certifier’s original signature. We cannot accept photocopies or faxes.
Books, Materials, and Equipment Accessories
Please check the boxes for any of these items you wish to receive:
Materials:
[] Books recorded on digital cartridge with specialdigital player
[] Braille and Audio Reading Download (BARD)
[] Books recorded on audiocassettes with special cassette player
[] Braille books and magazines
Accessories for Cassette book machines
[] Heavy duty headphones—for use where speakers are not permitted
[] Pillow speaker—for readers confined to bed
[] Amplifier—wewill send a separate application.
[] Remote control unit—we will send a separate application.
[] Breath switch
[] Extension levers
Accessories for Digital talking-book player
[] Heavy duty headphones & adapter—use where speakers not permitted
[] Pillow speaker & adapter—for readers confined to bed
[] Amplifier—wewill send a separate application.
Music materials available from the National Library Service
[] Check here if you are interested in music instructional materials, magazines and scores in accessible format. NLS will contact you.
Services from sources other than the National Library Service:
[] NFB Newsline Please register me for free newspapers by telephone.Kathy Gosselin, DC Administrator, .
Washington Volunteer Readers for the Blind records material not available in audio form for LBPH readers. Call us to learn more.
Learning AllyProvides downloadable audiobooks andeducational content for all ages and education levels. 800-221-4792 or www.learningally.org
Bookshare.orgprovidesbooks and newspapers for educational and
recreational use. Visit
The Metropolitan Washington Ear provides local information using a special radio. Contact 301-681-6636 or visit
How did you learn of the Library for the Blind? (This helps us plan outreach; it has no effect on your service.)
How will your books be selected? Checkone of the following:
[] Do not select books for me.Send only the specific titles I request.
OR
[] Please select books for me based on the interests marked below:
(You are still welcome to request specific items if we select for you.)
0Adventure Stories
0Bestselling Fiction
0Bestselling Nonfiction
0Bible studies
0Biographies
0Black concerns
0 Business/ Economics
0 Child care, parenting
0 Children's Fiction:
Reading level
0 Children's Nonfiction:
Reading level
0 Classic Novels
0 Cooking, nutrition
0 Drama, plays
0 Family chronicles
0 Fantasy
0 Folklore
0 Government, Politics
0 Health
0 Historical Fiction
0 History—U.S.
0 History—World
0 Humor
0 Illnesses, disabilities
0 Inspirational fiction
0 Modern fiction
0 Music appreciation
0 Mysteries
0 Nature, Ecology
0 Occult, Supernatural
0 Philosophy
0 Poetry
0 Psychology, Self-Help
0 Religion, creed
0 Romance
0 Science
0 Science Fiction
0 Short Stories
0 Sports
0 Spy Stories
0 Suspense Stories
0 Travel, Geography
0 War, War Stories
0 Westerns
I do not wish to receive books that contain (check all that apply):
[] Strong language[] Violence[] Explicit descriptions of sex
Language:[] English only [] Other:
Otherpreferences:
All DC patrons receive these items. Please check the format you prefer:
LBPH Inside the Beltway: A Newsletter
[] Large Print[] Audio[] E-mail
Talking Book Topics, a bi-monthly catalog of new books
[] Large Print[] Audio
You will receive a list of other audio and braille magazines available from the Library for the Blind in your welcome materials.
When this application is
completeand certified:
Fold with our address below showing.
Tape corners.
Place in any mailbox.
No postage needed.
FREE MATTER
FOR THE
BLIND OR
HANDICAPPED
DC Public Library
Adaptive Services, Room 215
901 G Street, NW
Washington, DC20001-4599