LISTENER APPLICATION FOR BROADCAST INFORMATION PROGRAM DEVICE

LISTENER APPLICATION FOR BROADCAST INFORMATION PROGRAM DEVICE
Welcome to MindsEye, an award-winning radio service for those who are blind or print disabled. Our programming provides readings of periodicals and books that would otherwise be unavailable to those who cannot read printed materials.

MindsEye’s closed-circuit SCA radios or Amazon Echo Dots are loaned to our listeners free of charge. Our broadcast can also be accessed through a listener's own smartphone, tablet, computer, Alexa, or Google device.

MindsEye is a United Way of Greater St. Louis Safety Net Member Agency.
Funding is also provided in part by contributions from listeners and friends.
Applicant Information
I would like to listen to MindsEye through*

MindsEye - SCA RadioMindsEye - Amazon Echo Dot**My own Amazon deviceMy own Google deviceMy own smartphone/tabletMy own computer
**To be eligible for a MindsEye - Amazon Echo Dot, you must have Wi-Fi, an email address, and an Amazon account (or be willing to create a new Amazon account).
Title

Mr.Mrs.Ms.Dr.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Please enter a valid phone number.
Cell Phone
Email
example@example.com
Would you like to be added to our email list?

YesNo
Birth Date*

MonthDayYear
Date
Marital Status

SingleMarriedDivorcedWidowed
Spouse’s Name
Program Schedules are available in 3 ways. Please choose one if needed.

Large PrintEmailAudio CD
How did you hear about MindsEye?

MindsEye ListenerMindsEye VolunteerNewspaperRadio/TVEventHealthcare ProviderAnother NonprofitUnited WayGovernment AgencyOther
Would you like to receive information about any of these other MindsEye programs?

Audio Description ProgramBeepBall Program
Secondary Contact Information

Please provide contact information of a family member, friend, or caregiver.
Secondary Contact Name*

First NameLast Name
Relationship to applicant*
Secondary Contact Phone*
Secondary Contact Email
example@example.com
Secondary Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Demographic Information

Answers remain confidential and are not used to determine eligibility for service. This information demonstrates that we serve a diverse audience as required by some funders, like the United Way.
Ethnicity (check all that apply)*

AsianBlack/African AmericanHispanic/Latino/LatinxNative American/Alaskan NativeNative Hawaiian/Other Pacific IslanderWhite/CaucasianPrefer not to sayOther
Gender Identity*

WomanManNonbinaryPrefer not to sayOther
Veteran Status*

YesNoPrefer not to say
Are you a member of the LGBTQIA Community*

YesNoPrefer not to say
Annual Household Income*

Less than $10,000$10,000 - $14,999$15,000 - $19,999$20,000 - $29,999$30,000 - $49,999$50,000 - $59,999$60,000 - $100,000More than $100,000Prefer not to say
Certification by Referring Agency

Physician, nurse, social worker, or other qualified person may need to be contacted to certify that the applicant cannot read or effectively use conventional printed material as a result of visual or physical limitations. Please provide the applicant's diagnosis and the physician's or referring agency's contact information for verification.
Specific medical diagnosis of the applicant’s visual/physical disability: (check all that apply)*

CataractsParkinson’s DiseaseCerebral PalsyRetinitis PigmentosaDiabetic RetinopathyStrokeGlaucomaMacular DegenerationOther
Physician or Referring Agency Name*
Physician or Referring Agency Phone Number*
Please enter a valid phone number.
Physician or Referring Agency Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician or Referring Agency Email
example@example.com
Applicant Authorization & Agreement

I have electronically signed on the space below or have personally requested this service and authorized that this application be signed on my behalf. I authorize the release by an agency, physician, or clinic of pertinent medical data to determine my eligibility for MindsEye. I understand that if I qualify for service, I may be loaned an SCA radio or Echo Dot, which is the property of MindsEye, and must be returned when I no longer need the service.
Signature*

Clear
Date*

MonthDayYear
Date
If you are filling out this application on behalf of the applicant, please list your name, relationship to the applicant, and phone number in case we need to contact you for further details.
First Name Last Name
Relationship to applicant
Area Code Phone Number
Please verify that you are human*
Should be Empty:

LISTENER APPLICATION FOR BROADCAST INFORMATION PROGRAM DEVICE

Applicant Information

Secondary Contact Information

Demographic Information

Certification by Referring Agency

Applicant Authorization & Agreement