Return this form to: LITBL/Suffolk Cooperative
Library System
627
(631) 286-1600 (24 hours)
(866) 833-1122 (Toll-free
for Nassau/Suffolk)
(631) 286-4546 (TTY for
Hearing Impaired)
APPLICATION FOR FREE LIBRARY SERVICE
FOR INDIVIDUALS
Please
print and complete all pages of this application. Records relating to the use of library
materials which contain names or other personally identifying details are
confidential. These records will not be
disclosed except upon request or consent of the library user or his or her
parent or guardian, or when required by law.
Please print or type
Name ________________________ ______________________ __________
Last First M.I.
Address ________________________________________________________
Village/Town ________________________ State _______ Zip ____________
Telephone _____________________ Birthdate
______________ Sex ______
Person to
be contacted about your Talking Book Service if you can not be reached
Name _____________________________ Telephone
____________________
Name of your local public library
____________________________________
Residency or
o Veterans: By law, preference in lending of books and
equipment is given to veterans. Check
here if you have been honorably discharged from the U.S. Armed Forces.
o Children
under 18: Check here if this
application is for a child under the age 18.
The “Parent Permission” section on the back page must be
completed and signed.
ELIGIBILITY AND CERTIFICATION
Please check the primary
reason that you are eligible to receive talking books.
o Blindness (blind 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).
o Visual Impairment (persons whose
visual disability, with correction and regardless of optical measurement, is
certified by competent authority* as preventing the reading of standard printed
material).
o Physical
Disability (persons certified by
competent authority* as unable to read or unable to use standard printed
material as a result of physical limitations).
o Reading
Disability (persons certified by
competent authority** as having a reading disability resulting from organic
dysfunction and of sufficient severity to prevent their reading printed
material in a normal manner).
o Deaf-Blind
In addition to any of the conditions above, do you
also have a hearing impairment? If yes, indicate the degree of hearing loss: o Moderate (some difficulty hearing and understanding
speech); o Profound (cannot
hear or understand speech)
To Be
Completed By Certifying Authority
*In cases of blindness, visual disability, or
physical limitation, “competent authority” is defined to include doctors of
medicine; doctors of osteopathy; ophthalmologists; optometrists; registered
nurses; therapists; professional staff of hospitals, institutions, and public or
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 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.
I
certify that the applicant named has requested library services and is unable
to read or use standard material for the reason indicated above.
Name
_________________________________________________________________
Title/Occupation _________________________________________________________
Address _______________________________ Telephone
_______________________
Signature __________________________________ Date
________________________
READING PREFERENCES
Reading Materials
ŸWhat type(s) of reading materials do you want?
o Books o Magazines o Scores, instruction or magazines about music*
ŸIn what formats would you like to receive these
materials?
o Recorded cassettes o Recorded Discs (records) o Braille**
*Materials about music provided form
the National Library Service for the Blind and Physically Handicapped
** Braille Materials provided from the Andrew Haskell
Library for the Blind and Physically Handicapped
Reading Equipment
ŸPlayback equipment and accessories are supplied to
eligible persons on extended loan. If
this equipment is not being used in conjunction with recorded reading material
provided by the Library of Congress and its cooperating libraries, it must be
returned to the issuing agency.
ŸDepending upon the formats specified above, we will
lend you a standard cassette and/or disc (record) player. If you require any other specialized
equipment or accessories (see cover sheet), please specify ____________________________________________
Frequency of Service
ŸMost talking book users are on a “return” system
whereby each time they return a talking book we send another. Check here o if you would like to receive books on this system.
ŸIf you would prefer a different type of service,
please check the appropriate box:
o Weekly o Biweekly oTriweekly o Monthly
How
many books would you like to receive on this basis? ________________
Book Selection (check one)
Ÿ o The library may select books for me based on the
reading preferences checked below.
Ÿ o Send only the specific titles I will request. Do not select books for me. (Note: You must
borrow books regularly in order to remain active in the program and continue to
use the equipment that has been loaned to you.)
Ÿ Do you want: oAdult books oYoung Adult Books
oChildren’s Book’s
(grade _____)
Ÿ Check if you do NOT
wish to receive books that contain:
o Strong language o Violence o Descriptions of Sex
Ÿ In which languages do you want to receive
books? o English o Spanish o French
o Italian o Other (specify _____________________________)
Ÿ FICTION
oAdventure oAnimal Stories
oBest Sellers oBlack Interests
oClassics
oFamily Stories oGothic Novels oHistorical Novels
oModern Novels
oModern Novels/Risque oMystery&Spy oOccult
oReligion (specify ______________) oRomance oScience Fiction
oWar Stories oWesterns
Ÿ NON-FICTION
oAdventure oBest Sellers oBiographies oBlack Interests
oBusiness oCooking oCurrent Events
oDisabilities oFine Arts oHealth oHistory oHomemaking oHumor oAbout Music oOccult oPhilosophy oPlays oPoetry oPsycology oPolitics&Government oReligion (specify ______________) oScience oSports oTravel oWar
Please
indicate any other type of books or favorite authors that interest you. Be as specific as possible.
_________________________________________________
Publications
You
will automatically receive the following materials to familiarize you with new
books and services. Please check the
reading format you prefer for each:
Ÿ Handbook for New Readers: olarge print ocassette
Ÿ Newsletter (bimonthly): olarge print ocassette
Ÿ Catalogs of Talking Books (annual): olarge print oflexible disc (record)
Ÿ Talking Books Topics (bimonthly): olarge print ocassette ocomputer disc oflexible disc (record)
PARENT
ACKNOWLEDGEMENT
This
section must be completed by the parent or guardian of applicants aged 18 or
less.
Ÿ I understand that the Talking Book Program is a free
service available to my child provided that he or she remains eligible for the
program and actively borrows materials from it.
Ÿ I understand that the LITBL lends recorded books for
leisure and recreational reading as well as literature and general nonfiction. I understand that the LITBL does not lend
textbooks on tape, nor does it lend playback equipment for the sole purpose of
listening to textbooks on tape.
Ÿ I understand that if my child does not borrow books
or magazines regularly from the LITBL, his or her service will be cancelled and
the equipment will be recalled.
Ÿ I agree to be responsible for the care and return of
all books and equipment.
Teachers occasionally contact our
office to make sure that their student(s) are registered to receive Talking
Books, and/or to order specific books for their students. May we respond to such requests from your
child’s teacher(s)? o yes o no
___________________________________ _______________________
Signature of parent
or guardian Date