Adult
Application for Library Services and Certificate of Eligibility
NAME OF APPLICANT
____________________________________________
C/O _____________________________________________________________
Street Address ____________________________________ Apt. No. _________
City
_____________________________________ State_______ Zip _________
Telephone
(_____)_______________ Date of Birth_______________
Sex _____
E-mail address _____________________________________________________
By law, preference in lending books and equipment is given to VETERANS. Please check here if you have been honorably discharged from the Armed Forces of the United States. _______
The above-named individual is unable to read or use normal printed materials as a result of the following physical limitation (See below for Definitions of Physical Limitations).
_____Visual handicap
_____Blindness
_____Deaf-blind
_____Physical handicap _____Reading disability
In addition to any of the conditions above, does applicant also have a hearing impairment? If yes, indicate degree of hearing loss. _____Moderate _____Profound
|
TO BE COMPLETED BY CERTIFYING AUTHORITY
I certify that the Applicant named has requested library service and is unable to read or use standard printed material for the reason indicated above. (Please print or type.)
Authority Name______________________________________________
Title and Occupation___________________________________________
Street_______________________________________________________
City________________________________
State________ Zip_________
Telephone___________________________________________________
E-mail address______________________________________________________
Authority Signature_________________________________Date_____________
DEFINITIONS OF PHYSICAL LIMITATIONS:
VISUAL HANDICAP: Lacks visual acuity to read standard printed materials
without special aids or devices other than regular glasses.
BLINDNESS: Visual acuity of 20/200 or less in the better eye with
correcting glasses or the widest diameter of visual field subtending
an angular distance no greater than 20 degrees.
DEAF-BLIND: Severe auditory impairment in combination with legal
blindness.
PHYSICAL HANDICAP: Unable to hold a book or turn pages as a result
of physical limitations. Examples include: without arms or the use of arms;
impaired or weakened muscle and nerve control; limitations resulting from
strokes, cerebral palsy, multiple sclerosis, muscular dystrophy, polio,
arthritis, or similar conditions.
READING
DISABILITY: Organic dysfunction of sufficient severity to prevent
reading printed materials in a normal manner. IF THIS
DISABILITY IS CHECKED, A MEDICAL (M.D.) OR OSTEOPATHIC (D.O.) DOCTOR MUST
SIGN.
This CERTIFICATE OF ELIGIBILITY must be completed and signed by a competent authority OTHER than the applicant's immediate family. In cases of blindness, visual impairment or physical limitations, "competent authority" is defined to include doctors of medicine and osteopathy, optometrists, registered nurses, therapists, professional staff of hospitals, institutions and public welfare agencies (such as social workers, case workers, counselors, rehabilitation teachers and superintendents). In the absence of any of these, certification may be made by a professional librarian or by any person whose competence under specific circumstances is acceptable to the National Library Service (NLS) for the Blind and Physically Handicapped, Library of Congress, Washington, DC. NLS administers the federal law under which the New Jersey Library for the Blind and Handicapped operates.
ALTERNATE CONTACT
In case we need to contact the Applicant but cannot, is there someone whom we can contact? (If the Applicant is a child, give parent's name.)
Alternate Contact's Name _______________________________________________
Home Telephone: (_____)_______________ Work Telephone: (_____)_______________
MATERIALS AND SERVICES AVAILABLE (Please check materials and services wanted.)
Book Formats:
[ ] Books on Cassette [ ] Books in Braille [ ] Large Print Books
EQUIPMENT (needed to play cassettes)
[ ] Standard Cassette Playback Machine (C1)
RETURN OF EQUIPMENT
Playback equipment and special attachments are supplied to eligible persons
on extended loan. If this equipment is not being used in conjunction
with recorded reading material provided by the New Jersey Library for
the Blind and Handicapped, it must be returned. Patrons must borrow
a minimum of one (1) recorded book per year to remain active with the
library.
SPECIAL ATTACHMENTS FOR C1 MACHINE (Please check only those items needed.)
[ ] Extension levers - assist the physically handicapped in manipulating the function keys of a C-1 cassette book machine.
[ ] Pillow speaker - available to readers who are bedridden.
[ ] Headphones. Regular style.
[ ] Amplifier/headphone system - available for the use of the severely hearing-impaired, as certified above. This attachment is loaned from the Library of Congress. If you indicated a need for any of these attachments, the appropriate application forms will be sent to you.
[ ] Remote control unit – available for bed-ridden or limited mobility patrons.
[ ] Breath switch – available for severally physical impaired patrons.
SERVICES
[ ] Audiovision Radio Reading Service. Listen to local and national news with special pre-tuned receiver/Internet account.
[ ] NFB-NEWSLINE: newspapers, magazines and the New Jersey Information Channel by touch-tone phone. (Sponsored by the NJ Commission for the Blind and Visually Impaired.)
[ ] Descriptive videos. (This is the only NJLBH service which is not tax-supported. It is funded by the Friends of NJLBH. One-time registration fee for video service is $20. Please enclose check made out to the Friends of the NJ Library for the Blind and Handicapped. We will send you a list of videos available for loan. You may borrow one video at a time for up to one month.)
CIRCULATION OF MATERIALS
The loan period for books is three months. (Please check ONE of the following.)
[ ] Do not select books for me. Send only the specific titles I request.
OR
[ ] I wish to have books selected for me from the following subjects:
SUBJECTS |
||
___ Biographies (specify) _____________________ |
___History |
___Religion (specify) ___________________ |
___Black experience |
___Horror/Occult Stories |
___Romances |
___Business |
___Humor |
___Science Fiction |
___Christian literature |
___Jewish experience |
___Sea Stories |
___ Classics |
___Latino experience |
___Short Stories |
___ Crime (Non-Fiction) |
___Modern Novels |
___Sports (specify) __________________ |
___Computers |
___Mysteries |
___Spy stories |
___Fantasy |
___Nature and Animals |
|
___Gardening |
___New Jersey Literature |
___Travel |
___Gothic |
___Philosophy |
___War (Non-fiction) |
___Historical Fiction |
___Poetry |
___Westerns |
Other subjects of interest to you that we did not list, or favorite
authors whose books you prefer to read:
_____________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________
PERSONAL PERFERENCES:
1) I do NOT wish to receive books that:
[ ] Contain Strong Language. [ ] Contain Violence. [ ] Explicit Description of Sex.
2) Languages: Will you borrow books in other languages besides English?
NO _____ YES ___ Languages (Specify):________________________
3) My reading level is: Adult _____ Other (Specify): _________________
THE FOLLOWING BI-MONTHLY PUBLICATIONS LIST NEW BOOKS (Please indicate the one you want by checking the desired format.)
TALKING BOOK TOPICS (Check one): Large Print [ ] Cassette [ ]
BRAILLE BOOK REVIEW (Check one): Large Print [ ] Braille [ ]
MAGAZINES: The New Jersey Library for the Blind and Handicapped has a list of 75 magazines which are available at no charge to registered patrons. The magazines are in Braille or on cassette. If you would like a list of available magazines, then check here [ ].
LIBRARY NEWSLETTER. How would you like to receive our newsletter?
Large print [ ] Braille [ ] Cassette [ ] E-mail [ ]
HOW DID YOU LEARN ABOUT OUR SERVICES?
[ ] Commission for the Blind & Visually Impaired [ ] Conference (for/about the Blind)
[ ] Family or Friend [ ] Health care provider(doctor/nurse)
[ ] LBH presentation [ ] LBH website (www.njlbh.org)
[ ] Public library [ ] TV, radio, newspaper, magazine
[ ] Other (please explain):
_____________________________________________________________________________
_____________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________
June, 2007
MAIL THIS COMPLETED APPLICATION TO THE ADDRESS BELOW.
FOLD ALONG THE LINE AND STAPLE OR TAPE CLOSED.
FREE MATTER FOR THE
BLIND AND HANDICAPPED
NEW JERSEY LIBRARY FOR THE BLIND AND HANDICAPPED
PO BOX 501
2300 STUYVESANT AVENUE
TRENTON, NJ
08618