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“Our mother loved books. When macular degeneration made it impossible for her to read, your programs really helped fill the void.” - Jane, daughter of a MindsEye listener

MindsEye Application for Service
Receive a MindsEye Radio by filling out the following form. MindsEye’s listeners are invited to use a loaned radio for as long as they need it. Some listeners have had the same radio for over 30 years! The listener who was loaned the radio is considered responsible for its return when it is no longer needed or when it needs repair. Please do not pass the radio on to someone else.
Listener Title (*)
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Listener Name(*)
Please let us know your name.
Name to mail to if different from listener
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Address(*)
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City(*)
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State(*)
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Zip Code(*)
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County of Residence (*)
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Email Address
Please let us know your email address.
Home Phone(*)
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Cell Phone
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Birth Date(*) / /
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Marital Status
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Spouse Name
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How did you hear about MindsEye -Check One(*)
Please Choose One
Other
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Would you like access to mindseyeradio online to hear live and archived programs from MindsEye on your computer(*)
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Program Schedules are available in four formats-- Which would you like(*)
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Additional Contact information --- Please provide two additional family members with different addresses and phone numbers
Name -- Contact 1(*)
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Relationship -1(*)
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Address -1(*)
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City State Zip -1(*)
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Home Phone -1(*)
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Cell -1
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Email Address -1
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Name -- Contact 2(*)
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Relationship -2(*)
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Address -2(*)
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City State Zip -2(*)
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Home Phone -2(*)
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Cell -2
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Email Address -2
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Answers remain confidential and are not used to determine eligibility for service. This information demonstrates that we serve a diverse audience as required by some funders, like the United Way.
Years of Education
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Gender
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Place of Employment
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Veteran
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Ethnicity --Please check all that apply
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Ethnicity -- Other
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Annual Household Income -- Please check one
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I have signed on the space below, or have personally requested this service and authorized that this application be signed on my behalf. I authorize the release by an agency, physician, or clinic of pertinent medical data to determine my eligibility for MindsEye. I understand that if I qualify for service, I will be loaned a radio, which is the property of MindsEye, and must be returned when I no longer need the service.