C O N N E C T I C U T R A D I O I N F O R M A T I O N S Y S T E M

Connecticut’s 184 Windsor Ave., Suite C

Talking Newsstand Windsor, CT 06095-4536

for the Blind Tel: (860) 527-8000 · Fax: (860) 727-9581

and Print-handicapped Website: www.crisradio.org

E-mail: crisradio@snet.net

Application for FREE Access to CRIS Programs

Personal Information

£ Mr. £ Mrs. £ Ms.

Last Name: First:

Address: City:

State: Zip: Date of Birth:

Home Tel: Bus. Tel:

E-Mail: Cell Phone:

I request: £ Radio Receiver £ Cable Information £ Telephone Reader access

Contact Person (Relative, Friend, or Caregiver)

Last Name: First:

Address:

City: State: Zip:

Home Tel: Bus. Tel:

E-Mail: Cell Phone:

CRIS Radio Equipment

CRIS radios are about the size of a tissue box.

Earphones are NOT included, but you may request an earphone jack.

Type of Radio Requested:

£ Electric Only £ Battery/Electric £ with Earphone Jack

Do you have cable TV? £ Yes £ No

Residence:

£ Private home £ Condo/Apartment £ Assisted Living

How would you prefer to receive your CRIS Program Guide?

£ Large Print £ Braille £ Cassette £ CD £ E-Mail

I Am Registered With:

£ The Connecticut Board of Education and Services for the Blind

£ Connecticut State Library – Library for the Blind and Physically Handicapped

Please Read and Sign This Agreement

I have personally requested access to receive CRIS programs and authorize that this application be signed on my behalf (if necessary). I authorize the release of medical information that may be required to determine my eligibility to access the programs of the Connecticut Radio Information System.

I also authorize the Connecticut Board of Education and Services for the Blind

(if I am registered with them) to share my contact information, including current address and phone number, with the Connecticut Radio Information System should they need it to update their files.

I understand that the radio receiver provided by Connecticut Radio Information System is on loan to me for as long as I need it. Should I no longer need or want the service, I (or someone acting on my behalf) will return the radio receiver to the Connecticut Radio Information System in the shipping box provided.

Signature or

Authorized Signature Date:

Print name of person signing _______________________________

CRIS Rev 01/08