How It Works

We require that you have official certification from a health care or other appropriate professional that you qualify for our services based on an inability to read standard print because of any of a variety of visual, physical and/or perceptual disabilities.  After you complete and submit the electronic form below, print the completed form, take it to your professional certifier for a signature and send it to us in the mail.

When you request the loan of a radio receiver from Sight into Sound, you must agree to return it when you no longer have a need for it or if you intend to move out of our broadcast area.

 

Today's Date

Date:                                         

Client Contact Information

Last Name:                                         
First Name:                                          
Address:                                          
City:                                          
State:                                          
Zip Code:                                          
Primary Phone Number:                                          
Secondary Phone Number:                                          
E-Mail Address: 
 

Client Demographic Information  
Ethnicity American Indian/Alaskan Native
Asian/Pacific Isl.
Black
Hispanic
White (not Hispanic)

Birth Date (please use numeric format MM/DD/YYYY):                                        

Alternate Contact
Please provide the name of a friend or relative who we may contact if we can't reach you directly.

Relationship to Client:                                          
Last Name:                                          
First Name:                                          
Address:                                          
City:                                          
State:                                          
Zip Code:                                          
Phone Number:                                          
E-Mail Address: 
 

Radio and Radio Guide
Would you  like us to send you a free loaner radio?

Yes, I need a loaner radio
No, I do not need a radio now

Please let us know how to send your Radio Guide:
Large Print Format
Cassette Format
Don't Need a Radio Guide

Source of Referral
Please let us know how you heard about Sight into Sound:
Lighthouse Houston 
Department of Assistive and Rehabilitative Services (DARS) of Texas
Veteran's Administration
Other Please specify
 
Certification of Client Eligibility
To be eligible for the full range of our services, including radio receiver loan and custom taping services, you must be certified by a professional in one of the categories below:
 
Relationship to Client

   Social / Rehabilitation Worker 
   Psychologist
   Ophthalmologist
   Optometrist
   Counselor
   Teacher 
   Medical Doctor
   Other Please specify    

Last Name:                                          
First Name:                                          
Address:                                          
City:                                          
State:                                          
Zip Code:                                          
Phone Number:                     
E-Mail Address:       
 

Professional Certification - Signature Area Please note that the Certifier Signature field must be physically signed in ink by the certifying professional.  All other fields in this section may be filled in online if desired.

Qualifying Disabilities:
 

Certifier Name (Please print):

I hereby certify that the client listed above is unable to read standard print because of the aforementioned visual, physical and/or perceptual disabilities.

Certifier Signature (Must be actual signature, in ink on paper):

Certification Date:                                          

When you click the Submit button below, a confirmation page displays the information you submitted. This information is sent to a Sight into Sound representative, who will enter your information in our prospective client database.  You still need to print the completed form, have your certifier sign it and send the signed, completed form to us by mail.

Note: Clicking the Reset button will clear all fields and will not submit the form information.