Connecticut radio information system connecticut’s 315 Windsor Avenue



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CONNECTICUT RADIO INFORMATION SYSTEM

Connecticut’s

315 Windsor Avenue


Talking Newsstand

Windsor, CT 06095 for the Blind


Tel: (860) 527-8000 Fax: (860) 727-9581 and Print-handicapped Website: crisradio.org E-mail: crisradio@snet.net




Application for FREE Access to CRIS Programs

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




Personal Information

□ Mr.

□ Mrs.

□ Ms.

Last Name:




First:

Address:




City:

State:

Zip:

Date of Birth:

Home Tel:




Bus. Tel:

E-Mail:




Cell Phone:




Contact Person (Relative, Friend, or Caregiver)

Last Name:

First:



Address:




City:

State: ______ ___Zip:

Home Tel:

Bus. Tel:

E-Mail:

Cell Phone:



CRIS Radio Equipment Earphones are NOT included, but you may request an earphone.




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





I Am Registered With:

□ The Connecticut Board of Education and Services for the Blind

□ Connecticut State Library – Library for the Blind and Physically Handicapped
I Authorize:

□ The Connecticut Board of Education and Services for the Blind

□ Connecticut State Library – Library for the Blind and Physically Handicapped
To share my contact information with the Connecticut Radio Information System should they need it to update their files.

Authorized Signature ____________________________Date :____/____/______



Note: If not registered with either of the above agencies, please have a physician, nurse, physical therapist, social worker or other individual in the allied health field complete the certification.

Certification of Disability

□ Blindness □ Visual Impairment □ Physical Disability □ Other ___________ The applicant cannot use conventional print as a result of the above disability. Certifying Authority____________________________Title___________________

Address______________________________________Phone_________________ Signature_____________________________________Date:____/____/________

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.

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

Signature of Applicant or Authorized Signature Date:____/____/________

CRIS Rev 06/09




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