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Outreach > Applications > Institution Application for Talking Book and Large Print
Institution Application for Talking Book and Large Print
Return this form to: Free Library Service for Institutions
Confidentiality: Records relating to the use of library materials which contain names or other personally identifying details are confidential and will not be disclosed except upon request or consent of the user or when required by law. Application: Please print or type.Name of Institution ______________________________________________ Address _______________________________________________________ City ____________________ State ________ Zip ______________ Telephone ____________________________ Name and title of staff member who will be responsible for this service: ________________________________________________________________ Number of persons unable to read or use standard printed material who will be served: ________ Type of Institution: ___ Nursing Home ___ Hospital ___ Library ___ School ___ Other (specify) ________________________________________________ Criteria for Eligibility
Criteria for Certifying Authority
To Be Completed by Certifying Authority I certify that the institution named serves persons who are unable to read or use standard printed material for one of the reasons specified above. I further certify that the reading materials and equipment borrowed will be used by such persons only. Please print or type. Name _________________________________________________ Title/Occupation _________________________________________ Address ___________________________ Telephone ___________ City _________________ State ________ Zip Code _____________ Signature __________________________________ Date ________ BorrowingBooks and MagazinesYou may borrow any of the following equipment. Please check those you wish to receive. ____ Talking books on cassette ____ Talking books on digital cartridge ____ Magazines on cassette ____ Braille Materials provided from the Perkins School for the Blind ____ Scores, instructions, and magazines about music in special media from the National Library Service for the Blind and Physically Handicapped. Individual applications must be submitted. EquipmentYou may borrow any of the following equipment. Please check those you wish to receive. ____ Standard cassette player ____ Standard digital player ____ Special equipment and accessories for readers with special needs (please specify) ____ Easy Cassette Player - for individuals who have difficulty operating the standard cassette player, this machine is simpler to operate but also less versatile. ____ Lightweight Headphones - issued only to readers who require them in order to be able to listen to talking books, as in nursing homes and hospitals where loudspeakers are not permitted. ____ *Amplifier - for persons with a significant hearing loss (medical certification required) ____ *Remote Control Unit - for persons confined to bed with difficulty in mobility, this device turns playback equipment on and off but will not control other functions such as volume and speed ____ *Breath Switch - for persons with little or no use of their extremities, to be used in conjunction with the Remote Control Unit ____ Extension Levers - for persons who have difficulty manipulating the key controls on the standard cassette player. ____ Pillowspeaker - for persons who are confined to bed, is placed under the reader's pillow and is normally heard only by the reader *A separate application form is required for these devices. If you are registered to receive Talking Books, you will automatically receive catalogs of Talking Books, Talking Books Topics (a bi-monthly publication announcing newly released books), and the Outreach Services handbook and newsletter. Deposit CollectionMany institutions maintain deposit collections of Large Print books which are exchanged periodically for different titles. Please indicate the number of talking books which you would like for a deposit collection: ___________ Frequency of Services____ Most users are on a "return" system whereby each time they return a book we send another. Please check here if you would like to receive books on this system. ____ Indicate quantity you would like to receive on this basis: _______ ____ Please check here if you would like receive books only when you request them Book Selection (check one):____ Send only the specific titles I will request. Do not select books for me. ____ The library may select books for me based on the reading preferences checked below: Reading Level: ____ Adult ____ Young Adult ____ Child (specify reading level ___________) Check if you do NOT wish to receive books that contain: ____ Strong Language ____ Violence ____ Explicit descriptions of sex Primary Language: ____ English ____ Spanish ____ French ____ Other, please specify: _______________________ Fiction
Non Fiction
Please indicate any other type of books or favorite authors that interest you. __________________________________________________________________________________ Certification of Student EligibilityPublic or private schools where disabled students are enrolled must submit a certification of eligibility for each applicant annually. Refer to Criteria for Eligibility to determine which students are eligible for talking book service, and who may serve as the certifying authority. Please note that students with reading disabilities who meet the criteria for eligibility must be certified by a doctor of medicine or a doctor of osteopathy. This is to certify that the following student(s) is/are unable to use standard printed material for the reason indicated:
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