LIBRARY FOR THE BLIND AND PHYSICALLY HANDICAPPED
Connecticut State Library
198 West Street
Rocky Hill, Connecticut 06067

Tel: 860-721-2020 or 1-800-842-4516 Fax: 860-721-2056

Application for Free Library Service: Individuals

(Institutions apply on a separate form.)

Notice: Records relating to recipients of Library of Congress reading material are confidential.

Please print or type
Name (Last)_______________________ (First)_______________________ (Initial)_____
Address (Street) __________________________________________________________
(City) ______________________ (County)____________ (State)__CT_____ (Zip)______
Telephone (_____)______________ Date of Birth _________________ Gender _________

Name of minor's parent/guardian:______________________________________________
Daytime telephone: (_____)_____________________________

Person to be contacted if you cannot be reached for an extended period:
Name __________________________________________ Telephone (____) __________

[ ] By law, preference in lending of books and equipment is given to veterans. Please indicate if you have been honorably discharged from the U.S. armed forces.

Indicate the primary disability preventing you from reading standard printed material. See definitions under eligibility criteria.
(Check only one box.)

[ ] Blindness	[ ] Physical handicap	[ ] Deaf/Blindness
[ ] Visual handicap	[ ] Reading disability (MEDICAL DOCTOR SIGNATURE REQUIRED. Refer to ELIGIBILITY CRITERIA Section C.)

In addition to any of the conditions above, do you also have a hearing impairment? If yes, indicate the degree of hearing loss:

[ ] Moderate. Some difficulty hearing and understanding speech.
[ ] Profound. Cannot hear or understand speech.

Reading Material And Equipment
You may borrow any of the following items. Check the formats, categories, and accessories you wish to receive. The recorded materials require the use of our equipment due to special speed and formatting. 

Talking books on cassettes
and
[ ] Standard cassette machine
or
[ ] Easy cassette machine (as available)

[ ] Braille books

Accessories
[ ] Headphones (solely for use where loudspeakers are not permitted and for readers who need them to hear the material)
[ ] Remote control unit (special application required)
[ ] Breath switch (special application required)
[ ] Extension levers (for physical limitations pushing machine buttons)
[ ] Pillowphone (solely for readers confined to bed)

Magazines
[ ]Braille
[ ]Flexible disc (requires Talking-book machine)

Music Materials
[ ] Music scores in Braille
[ ] Music scores in large print
[ ] Instructional recordings on cassette
[ ] Instructional recordings on disc
[ ] Music magazines in Braille
[ ] Music magazines in recorded form
(Note: Recorded music for listening is not available through this program.)

Return Of Equipment
Playback equipment and special attachments are supplied to eligible persons on extended loan. Equipment not being used in conjunction with the supplied reading material must be returned to the issuing agency.

Reading Preferences (Check one.)
[ ] Send only the specific titles I request. Do not select books for me.

[ ] Choose books for me in the categories checked below, if the specific requests I provide are not available:

[ ] Adventure stories [ ] Animals [ ] Bestsellers [ ] Bible and religion (denomination________) [ ] Biographies [ ] Classic novels [ ] Cooking and homemaking [ ] Connecticut topics [ ] Family stories [ ] Fine arts [ ] Gothic novels [ ] Health [ ] Historical fiction [ ] History-U.S. [ ] History-World [ ] Humor

[ ] About music [ ] Mysteries and Detective stories [ ] Occult and supernatural [ ] Philosophy and psychology [ ] Plays [ ] Poetry [ ] Politics and government [ ] Romance [ ] Science and nature [ ] Science fiction [ ] Sea stories [ ] Short stories [ ] Sports [ ] Spy stories [ ] Travel [ ] War stories [ ] Western stories

My other reading interests are__________________________________________

Please do not send me books that contain:
[ ] strong language
[ ] violence
[ ] explicit descriptions of sex

[ ] Check this box if you read English only, or list languages in which you are fluent, beginning with your native language: __________________________________________

Reading or interest level(s)
Juvenile: [ ] Preschool-2
[ ]K.-3 [ ]2-4 [ ]3-6 [ ]4-7
[ ]5-8 [ ]6-9

[ ]Junior and Senior High School
[ ]High School and Adult
[ ]Adult

Eligibility Criteria For Loan Service

1. The following individuals are eligible for loan service:
   1. Blind persons whose visual acuity, as determined by competent authority, is 20/200 or less in the better eye with correcting lenses, or whose widest diameter of visual field subtends an angular distance no greater than 20 degrees.
   2. Other physically handicapped persons as follows:
      • Persons whose visual disability, with correction and regardless of optical measurement, is certified by competent authority as preventing the reading of standard printed material.
      • Persons certified by competent authority as unable to read or unable to use standard printed material as a result of physical limitations.
      • Persons certified by competent authority as having a reading disability resulting from organic dysfunction and of sufficient severity to prevent normal reading of printed material.
2. In cases of blindness, visual disability, or physical limitations, "competent authority" is defined to include doctors of medicine; doctors of osteopathy; ophthalmologists; optometrists; registered nurses; therapists; professional staff of hospitals, institutions, and public or welfare agencies (e.g., social workers, case workers, counselors, rehabilitation teachers, and superintendents). In the absence of any of these, certification may be made by professional librarians or by any persons whose competence under specific circumstances is acceptable to the Library of Congress.
3. In the case of reading disability from organic dysfunction, competent authority is defined as doctors of medicine and doctors of osteopathy who may consult with colleagues in associated disciplines.
4. Qualified readers must be Connecticut residents.
5. Institutional requirements. Reading materials and sound reproducers may be loaned to institutions, such as nursing homes and hospitals, and to schools for the blind or physically handicapped for use by such persons only. Loans can also be made to public or private schools where handicapped students are enrolled provided the students are certified as eligible on an individual basis and are the direct and only recipients of the materials and reproducers. Institutions apply on a separate form.

To be completed by Certifying Authority
(For explanation of "certifying authority," refer to Eligibility Criteria Sections 'B' and 'C' above.)

I certify that the named applicant has requested library service and is unable to read or use standard printed material for the reason indicated on the front of this form. (Please print or type.)

__________________________________________________
Name Of Certifying Authority                                        Date

__________________________________________________
Title and Occupation

__________________________________________________
Street Address                                                              Telephone

__________________________________________________
City                                               State                              Zip

__________________________________________________
Signature Of Certifying Authority