Arizona State Library, Archives and Public Records Braille and Talking Books Division
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ARIZONA STATE BRAILLE
AND 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.

 

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Updated:  09/27/2007

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comments to:
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