Reachout Radio

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:

Prefix:

Mr.
Mrs.
Ms.
Full Name:
Date of Birth:
Street Address:
City, State and ZIP code:
County:
Is this a multi-resident facility?:
No
Yes
Name of facility:
Telephone:
Home:
Work:
E-Mail Address:
Occupation:

Contact person:

Telephone:

Next of Kin or Secondary Contact (residing at a different address):

Full Name:
Relationship:
Street Address:
City, State and ZIP code:
Telephone:

Program Guide Format Desired:
large print
cassette
braille

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

Do you listen to WXXI on 91.5 or 90.3?

If you live outside Rochester, do you have cable access?
No
 Yes
Company:

Are you registered with:
A. The NYS Commission for the Visually Handicapped? Yes No *
B. The Library of Congress Talking Books Program? Yes No *

Required Certification of Disability: * If you answered NO to both A & B, please print the certification form and have it completed by a physician, nurse, social worker, rehabilitation counselor or other qualified individual. If you answered YES to either A or B, completion of the certification is optional. However, this information is helpful to us to serve you better.

PLEASE READ THIS AGREEMENT:

I have personally requested this service and authorize that this application be signed on my behalf (if necessary). I authorize the release by any agency, organization, doctor or clinic of medical data needed to determine my eligibility for the radio reading service. I am aware that the receiver is on LOAN to me and shall remain the property of WXXI REACHOUT RADIO. In the event that I no longer need the service, I will return the receiver to WXXI REACHOUT RADIO at the address above.

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