| New York State Library | Talking Book and Braille Library |
Notice: Records relating to recipients of Library of Congress reading materials are confidential and will not be disclosed without the consent of the individual. (New York State Civil Practice Law and Rules, Section 4509, 1982, 1988).
Please print or type.
Name (Last)___________________________(First)_______________(Initial)____
Street Address_______________________________________________________
City__________________________County_____________State_____Zip_______
Telephone_________________Date of Birth_____________Grade____Sex______
Indicate the primary disability which prevents the child/teen from reading standard printed material. Check only one. Must be certified by proper authority.
Parent/Guardian: I understand that my child will now be registered with the NYS Talking Book & Braille Library in Albany, NY. He/she will be loaned a cassette player, books on tape and/or books in braille, and catalogs. I will return all materials to the Library (not to my child's school) if they are no longer needed.
Name_________________________________________Relationship__________
Address_______________________________________Phone________________
A Program of the U.S. Library of Congress and NYS Education Department, New York State Library
Service Requested (Choose one or both)
___ Recorded books and/or magazines on cassette; loan of special cassette playerAttachments/Accessories for Cassette Players
___ Amplifier headphone (available only to readers with profound hearing impairment; additional medical certification form will be sent to you)The Library will ship several books on tape or in braille to get you started unless you submit an order now. Please contact the Library to order specific books.
Reading Interests
___ Adventure__________________________________________________________________
My other reading interests are__________________________________________
(Please keep the Library updated as reading level and interests change.)
___ Magazines (We will send you a listing of recorded and braille magazines.) Grade/Interest Level (may be different from actual age) ___ Preschool - 3rdDo not choose books for me which contain:
___ ViolenceLanguages other than English
We will send books in English unless you request other languages. There are some titles in Spanish and a more limited number in other languages. If you want books in other languages, please tell us which: __________________________________
To Be Completed by the Certifying Authority
Refer to Sections B and C of the U.S. Federal Government regulations governing library service to blind, physically handicapped, and reading disabled persons. *Note* An M.D. must sign for reading disabled/learning disabled student.
I certify that the applicant named has requested library service and is unable to read or use standard printed material for the reason indicated on page one of this form. Please print or type. Only an original signature is acceptable.
Name of Certifying Authority_______________________Title_______________
Place of Employment/Affiliation________________________________________
Street Address_________________________________Telephone _____________
City____________________________State__________________Zip__________
Signature__________________________________________Date_____________