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Library for the Blind and Print Disabled

Library@blind.state.ia.us

524 4th St Des Moines, IA 50309

515-281-1323

Application for Free Library Service

Iowa Library for the Blind and Print Disabled

The Iowa Library for the Blind and Print Disabled provides services to individuals with:

  • Blindness
  • A visual disability that prevents the reading of standard printed material.
  • A physical disability, such as multiple sclerosis, paraplegia, or paper allergies, that interferes with the ability to hold a book and turn pages.
  • A reading disability resulting from organic dysfunction.

Hospitals, nursing or convalescent homes, schools or other institutions serving visually or physically disabled persons may also register with the library.

Certification

Applications for LBPD service must be certified by a competent authority.

In the case of visual or physical disability, a competent authority is defined to include:

  • physician
  • osteopath
  • ophthalmologist
  • optometrist
  • registered nurse
  • therapist
  • professional staff of hospitals, institutions, and public or welfare agencies (e.g., social worker, case worker, counselor, rehabilitation teacher, or superintendent).
  • professional librarian

More information about the certification for individuals with reading disabilities may be found in Talking Books and Reading Disabilities, a factsheet produced by the National Library Service for the Blind and Print Disabled.

Full Name

Date of Birth

Full Address

Gender

Additional Information

Contact Person: Person to contact if you can’t be reached or can assist with your account:

Contact Person Name

Contact Person Information

Indicate the primary disability preventing you from reading standard print material.

Select one:

Certifying Authority Information 

In the case of visual or physical disability, Please list below a competent authority is defined to include:

  • physician
  • osteopath
  • ophthalmologist
  • optometrist
  • registered nurse
  • therapist
  • professional staff of hospitals, institutions, and public or welfare agencies (e.g., social worker, case worker, counselor, rehabilitation teacher, or superintendent).
  • professional librarian
  • Can even be a close friend or neighbor

THE CERTIFYING AUTHORITY CANNOT BE THE APPLICANT OR A FAMILY MEMBER. 

Certifying Authority Information

Facility

Facility Address

National Library Service for the Blind and Print Disabled Parental/Guardian Acknowledgement

As the parent/guardian of the Iowa Library for the Blind and Print Disabled patron, I acknowledge that my child will receive services and equipment and that my child will have access to the entire National Library Service for the Blind and Print Disabled (NLS) catalog of reading material. All materials and equipment (including digital talking-book cartridges, hard-copy braille, players, and accessories) must be returned when no longer needed.

Parent/Guardian Full Name

Which library services would you like?

All books and equipment can be sent and returned through the mail free of charge. Please select below the services you would like to receive. You may check multiple services.

 

 

Books:

Please send me information on other services:

Reading Preferences

Complete the following if you would like library materials sent by home delivery, USPS Free Matter for the Blind.

Receiving Books (Choose One Option):

Do we need to exclude books containing the following?

Preferred Language for Reading

What would you like to read?

Subject Category:

Are you interested in Magazines?

What format would you like to receive magazines? (select all that apply)

Descriptions of each magazine can be found on the NLS website.

Audio Magazine

Braille Magazines

How did you learn about the NLS free library service (check up to 3 that apply?)

Equipment Policy:  Playback equipment and special attachments are supplied to eligible persons on extended loan.  If this equipment is not being used in conjunction with reading material provided by the Library of Congress and its cooperating libraries, it must be returned to an issuing agency.  Your cooperation in returning these items in a timely manner is appreciated.

 

Confidentiality:  The information required on this application pertains to eligibility for free library services for the blind and physically disabled individuals.  This information is required by the National Library Service for the Blind and Print Disabled of the Library of Congress to fulfill the requirements of Public Law 89-522.  Complete and accurate information will speed up the application process.  All library records, including this application, are considered to be confidential in accordance with the Code of Iowa Chapter 22.7(13).