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Application for Accessibility Services

Current Part 1: Personal Information
Part 2: Delivery Service
Part 3: Eligibility for Accessible Formats
Part 4: Equipment
Part 5: Reading Profile
Complete

First Name

Last Name

Address

Address 2

City/Town

Postal Code

Phone

Date of Birth

Gender

	Nature of Disability/Reason for Service
I have a learning disability such as a perceptual impairment	I have a learning disability such as a perceptual impairment
I have a physical disability such as the inability to hold or manipulate a book	I have a physical disability such as the inability to hold or manipulate a book
I have an impairment of sight, or inability to focus or move my eyes	I have an impairment of sight, or inability to focus or move my eyes
I have a mobility challenge such as an illness, injury or disability that prevents me from visiting the library, carrying library materials or leaving my home for an extended period	I have a mobility challenge such as an illness, injury or disability that prevents me from visiting the library, carrying library materials or leaving my home for an extended period
I have a severe or total impairment of hearing	I have a severe or total impairment of hearing
I am a senior without transportation	I am a senior without transportation

Secondary Contact

Phone

Relationship to Applicant

Customer Authorization

I give Surrey Libraries permission to keep a list of books checked out to me in order to avoid receiving duplicates. I agree to be responsible for all materials delivered to me, and to abide by the rules and regulations of Surrey Libraries.

Please sign below.

Parent/Guardian Signature

For children under 12 or an incapable minor under 19, a parent’s or guardian’s signature is also required

Please sign below.