ARIZONA TALKING BOOK LIBRARY

ANNUAL STUDENT CERTIFICATION FORM FOR SERVICE TO PUBLIC OR PRIVATE SCHOOLS



The following student will be served by:
School Name

Phone
( ) -

Address
City

State
ZIP
Student Name
DOB
Address (Home)
City
State

 ZIP
Reading Grade Level

Student Phone
( ) -
Student to have a Personal Account?     Yes     No
Disability
DISABILITY STATEMENT: Please include a brief written statement of student's disability and/or medical doctor's certification for student with reading disability caused by organic dysfunction.
*** This portion must be completed or the application will be returned to you. ***


Visual Handicap (not able to read print with corrective lenses)
Legally Blind
Physical Handicap (not able to hold book/turn pages)
Reading Disability Caused From Organic Dysfunction
           This disability must be certified by a medical doctor.


Certified by

___________________________________
 
Title

___________________________________
Date

___________________________________
Signature

___________________________________
Phone

___________________________________
   
Please print the form by clicking on the link below. Then proceed to the next application to finish the form.