Audio Reading Service

I would like to register for new service
I would like to update my existing listener information

Listener Name

First Name *

M.I.

Last Name *

Date of Birth *

Address

Street Address *

Address Line 2

City *

State/Province *

Zip *

Country *

Primary Phone *

Secondary Phone

What is your print disability/reason requesting service? *

Are there any other medical conditions we should know about?

How did you learn about the Audio Reading Service? *

Optional items for statistical purposes and to help us apply for grant dollars to continue our service.

Race

Income

Number in Household

Program Schedule (tells the day/time programs are aired) - Choose Your Preferred Format *

Large Print
Braille
Audio CD
Email

Choose your preferred media for listening

HD Radio
Online Website/Streaming
Podcasts
App - Apple
App - Android
App - Kindle
TV
Smart Speaker

Please Check One *

Mail radio to listener
Mail radio to contact person
Other:

Alternative Contact Name

First Name *

Last Name *

Relationship to Listener *

Address

Street Address *

Address Line 2

City *

State/Province *

Zip *

Country *

Primary Phone *

Secondary Phone

STATEMENT OF AGREEMENT AND RESPONSIBILITY

I understand that the Audio Reading Service programming is intended solely for individuals who are visually impaired or have other reading challenges, and may not be broadcast or redistributed without the consent of the Audio Reading Service. As an individual listener and/or authorized contact, any radio loaned to me by the Audio Reading Service is on loan from and remains the property of the Allen County Public Library. I agree that I, my authorized contact, or other responsible persons will return the radio when no longer in use, by mailing to the Audio Reading Service at 7615 DiSalle Blvd., Fort Wayne IN 46825 or by dropping it off at any branch of the Allen County Public Library, with my name and reason for return included.

Signature of responsible party *

I have read and agree to statement terms *

To return or request replacement radio - take radio to any Allen County Public Library branch, staff will forward to the Audio Reading Service. Be Sure to include your name, address and reason for return. If a replacement radio is needed please include a note to let us know. Thank you!

APPLICATION FOR AUDIO READING SERVICE RADIO