Reachout Radio

Facility Receiver Application

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

To obtain a receiver, you may submit the data below:

Facility Name:
Department/Floor:
Street Address:
City, State and ZIP code:
County:
Telephone:
E-Mail Address:

Contact Person:

Title:

Contact Telephone:

Extension:

Is this facility a:
nursing home retirement community assisted living center hospital other:
Approximately how many people will benefit from the receiver?:
Program Guide Format Desired:
large print
cassette
braille

Type of Receiver Desired:
table top
portable (requires batteries)
Orders are filled as available.

Does your facility have a closed-circuit in-house system?
No
 Yes

PLEASE READ THIS AGREEMENT:

I understand that this receiver is on loan as long as we are using it, and that if any time we discontinue its use, I agree to return it to WXXI Reachout Radio.

To authorize, please type your full name and today's date below: