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IRIS LISTENER APPLICATION

Title
First Name
MI
Last Name
Date of Birth
 (Please use the format 1/1/02)
Street Address
Apt. No.
City
State
Zip
 (5 digits)
Phone
E-Mail
Occupation
Employer
Race
Retired
 Yes No
How did you learn about IRIS?
Please list two (2) individuals who will be responsible for returning the IRIS receiver if the applicant cannot do so:
Alternate 1.
  
Name
Relationship
Address
Apt.
City
State
ZIP
Phone
Alternate 2.
  
Name
Relationship
Address
Apt. No.
City
State
ZIP
Phone

Eligibility Requirements

Please check the appropriate category(s):
Legally Blind
Visual Impairment
(Inability to read standard printed material without special aids or devices other than regular reading glasses)
Physical Impairment
(Inability to read or use standard printed material as a result of physical limitations)
Specify:
Reading Disability
(Organic dysfunction of sufficient severity as to prevent the reading of printed material in a normal manner)
Illiteracy
  Are you enrolled in the Talking Book Program?
Yes No
 

If YES, please SUBMIT this form to IRIS.

If NO, certification must be sent to IRIS by a medical or other professional provider. The certifying authority may NOT be a relative of the applicant.
   
Applicant's Signature:
 ________________________________
   
Date:
 ________________________________
  This form may be printed out and faxed to (317) 633-7418.
   
 

 

IRIS Home       Dial-Up Service       Listener Application
Volunteer Application       Reading Schedule
Enhanced IRIS site       WFYI