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Braille Tales Application
Please complete this form to enroll in the APH Partners Print/Braille Book Program. The information will ensure delivery of your child’s free print/braille books.
Child's Information
Name
(Required)
First
Last
Birth Date
(Required)
Month
Day
Year
Gender
Prefer not to respond
Male
Female
Braille Usage
(Required)
Child is a braille reader or is likely to use braille as his/her future reading medium
The parent or legal guardian of the child being registered is a braille reader
Agency or organization providing support services
Parent or Legal Guardian Information
Title
Name
(Required)
First
Last
Shipping Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Guam
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
Northern Mariana Islands
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Puerto Rico
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
United States Minor Outlying Islands
U.S. Virgin Islands
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
County
(Required)
Email Address
(Required)
Phone Number
(Required)
Guardian Status
I am the child's parent
I am the child's legal guardian.
I am a third party filling out application.
If you are the child's legal guardian, please indicate whether you are a grandparent, aunt/uncle, foster parent, etc.
If you are a third party filing out the application please provide a name/title and contact info
Questions contact Christine Genovely: 502-899-2300,
brailletales@aph.org
.
Phone
This field is for validation purposes and should be left unchanged.
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