Application for Service -- Children and Teens

Children/Teens Application for Library Services and Certificate of Eligibility

NAME OF APPLICANT ______________________________________________

CONTACT PERSON: ________________________________________________

Street Address: ____________________________________ Apt. No. _________

City _____________________________________ State_______ Zip _________

Telephone (_____)____________ Date of Birth__________ Grade____ Sex _____

E-mail address _____________________________________________________

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

The Library for the Blind and Handicapped is supported by the New Jersey State Library and is funded by the Institute of Museum and Library Services through its Grants to States program.

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.

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.
PERSONAL PERFERENCES:
1) Languages: Will you borrow books in other languages besides English?
NO _____ YES ___      Languages (Specify):________________________
2) My reading level is: P-2[ ] K-3[ ] 2-4[ ] 3-5[ ] 4-7[ ] 5-8[ ] 6-9[ ] High School[ ]
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 (Continued on next page)
[ ] I wish to have books selected for me from the following subjects (next page):

Reading Interests:
Adventure [ ]                          Animals [ ]                                       Children's Classics [ ]
Family Stories [ ]                     Fantasy [ ]                                        Friendship [ ]
History - American [ ]            History – Foreign [ ]                Historical Fiction [ ]
Sports [ ] (Specify):___________________                                     Humor [ ]
Mysteries [ ]                           Nursery Rhymes/ ABC's [ ]     Occult/Supernatural [ ]
Poetry [ ]                                 Religion [ ]                                        Romance [ ]
Science [ ]                                Science Fiction [ ]                    Westerns [ ]
Other subjects of interest to you that we did not list, or favorite authors whose books you prefer to read:
__________________________________________________________________________________________________________________________________
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. Below are the children’s magazines. Please select:
Cassette:    Cricket [ ]   National Geographic for Kids [ ]   Spider [ ]   Teen People [ ]
Sports Illustrated For Kids [ ]   Young Adult Magazine of the Month [ ]
Braille:      Boys Life [ ]   Conundrum [ ]   Muse [ ]   Seventeen [ ]   Spider [ ]
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): _______________________________________________________

NEW JERSEY LIBRARY FOR THE BLIND AND HANDICAPPED
PO BOX 501
2300 STUYVESANT AVENUE
TRENTON, NJ 08618