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Minds Eye Information Service


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Registration Form

Welcome to Minds Eye Information Service, award winning radio for those who are blind or print disabled.

Our programming provides readings of periodicals and books that would otherwise be unavailable to those who cannot read printed materials.

The Minds Eye is provided to our listeners free of charge by the generosity of our donors like the United Way. Funding is also provided in part by contributions from listeners and friends.

To apply for free membership and use of the Minds Eye listener website, please provide the following information.


Login Information:    Please enter an email address, user name, and password. User name and password must be between 5 and 25 characters. Your user name will be used to login to the listener website so please be sure to enter a user name that is easy to remember like your email address.

(Required) Email:
(Required) Username:
(Required) Password:
(Required) Password Confirmation:


Personal Information:    Please enter the following information so that we may better serve you.

(Required) Name:
Company:
(Required) Address:
(Required) City:
(Required) State:
Country:
(Required) Home Phone:
Birth Date:
How did you first hear about us?:
 
Demographic Information:    Information required by Minds Eye funders like United Way to determine that we serve a diverse audience. Answers are not used in determining eligibility for service and will remain confidential. (none required)

Years of Education:
Gender:
Place of Employment:
Ethnicity:
Annual Household Income:
 
Eligibility:   

Visual or Physical Handicap:
If other, visual or physical handicap:
 
Ophthalmologist’s, Optometrist’s, or Physician’s Name
(Required) Physician's Name:
Physician's Address:
Physician's City:
Physician's State:
Physician's Zip Code:
 
Applicant’s Authorization & Agreement:    I have initialed on the box below. I authorize the release by an agency, physician, or clinic of pertinent medical data to determine my eligibility for Minds Eye Information Service. (none required)

(Required) Initials:


Other Information

Subscription: (Newsletter subscription)




Some information (such as newsletter subscriptions) may be modified after registration.
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