BOOKS ALOUD, INC.
P.O. Box 5731 San Jose CA 95150
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Name
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Phone #
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Address
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Disability
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City State Zip Code
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Date of Birth
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E-mail
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Do you read Braille? Yes No
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Closest Relative or Friend
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Phone #
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Address
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Relationship
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City State Zip Code
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Referred by
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E-mail
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# Books Desired per Month
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Subject/Author Preference
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Do you object to: Strong Language?_______ Explicit Sex?_______ Violence?_______
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Tapes Used In |
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# of People Served |
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Home (Individual) |
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Outlet |
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Special Ed Class |
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Chapter |
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Day of Month |
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Medical Verification Received |
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Catalog Sent |
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Number of Albums |
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Date_______________________ |
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Date___________ |
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Reading Level |
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AVI
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GOT
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HUM
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SCI
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SPY
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WHI
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J-BIO
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J-NAT
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BIO
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HEA
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MYS
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SEA
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STL
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J-CLA
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J-POE
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CHR
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HER
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NAT
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SER
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STW
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J-FIC
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J-POE
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CLA
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HIS
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POE
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SHO
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TEC
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J-HIS
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J-SER
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FIC
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HOL
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REL
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SPA
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TRA
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C-FIC
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J-MYS
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J-SPO
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Comments_______________________________________________________________________________
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FOR OFFICE USE ONLY
Prepared by (initials/date) ____________ Donor Perfect (initials/date) ____________
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