Reachout Radio

Certification of Disability

This form must be printed and mailed to:

Or print the PDF version of the form.

Reachout Radio
280 State Street
P.O. Box 30021
Rochester, NY 14603-3021


Name of Applicant:

 

Please explain the nature of the disability which qualifies this individual as print handicapped*

Please be specific:

* Print handicapped is defined as the inability to access conventional printed information due to a visual impairment, a learning disability, or a physical impairment which prohibits the holding of reading material.

Only one of the following descriptions is necessary.

Visual Impairment:

 

 
Physical Impairment:

 

 

 
Other (please specify):

 
I do hereby certify that the applicant named above is unable to use conventional print as a result of the disability described:

Certified by: (Name of professional)

Title:

Street Address:

City, State and ZIP code:

Telephone:

Today's Date:

Signature: