Client Name:_________________________________________________________________________
Address:_____________________________________________________________________________
City, State, Zip:____________________________________________________________________
Phone:_______________________________________________________________________________
Books Aloud, Inc. is a private, nonprofit organization that records books on cassette tape for free loan to the visually, physically, or learning disabled.
Written verification of disability is required to meet copyright laws and postal regulations. Acceptable signatures include doctor, nurse, optometrist, ophthalmologist, therapist, teacher, or social worker. Letters, prescription forms, or school IEPs may also be used.
Authorized Personnel: (Type or Print)
Name:______________________________________________Title:_____________________________
Address:______________________________________________________________________________
City, State, Zip:_____________________________________________________________________
Phone:________________________________________________________________________________
Signature:_________________________________________Date:______________________________
Description of disability:____________________________________________________________
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Definition of Blindness: The term "blind" means an individual whose central visual acuity does not exceed 20/200 in the better eye with correcting lenses, or whose visual acuity is greater than 20/200 but is accompanied by a limitation in the fields of vision such that the diameter of the visual field subtends an angle no greater than 20 degrees. (Section 23-y-2 of the Revenue Act of 1944). Eye surgery, limited vision, and difficulty in reading conventional print also provides eligibility.
Physically Disabled: A person who is unable to hold a book or turn the pages is also eligible. Examples: quadriplegic, stroke, MS, CP, cancer, Immune Deficiency Syndrome, etc.
Learning Disabled: Some people with learning disabilities such as dyslexia and mental retardation are also eligible.
Please sign and return to: Refer questions to our office at:
Books Aloud, Inc. P.O. Box 5731 San Jose, CA 95150-5731 Phone: 408-808-2613 Fax: 408-808-2625