Lending Library Product Request Form

Families, teachers and educators of children who are visually impaired/blind or deafblind may borrow products from the Product Lending Library for up to 3 months.

These resources are provided so that one can trial products or determine whether the product may be helpful to purchase.

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* 1. NAME OF THE PRODUCT FROM CATALOG YOU ARE REQUESTING

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* 2. ADDRESS AND CONTACT INFO TO SEND YOUR PRODUCT

Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

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* 3. NAME OF YOUR SCHOOL AND COUNTY

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* 4. Who are you?

I am blind/visually impaired/have low vision

I am a parent, guardian, or teacher of someone who is blind/visually impaired

Other (please specify)

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* 5. Is the student/child registered with the APH Federal Quota?

Yes

I do not know