Application for a Virginia Voice Receiver

A Virginia Voice radio enables the recipient to listen daily to the reading of the Richmond Times Dispatch and several other daily newspapers as well as a host of magazines and occasional books. In addition, the programming includes informal programs produced specifically for those with visual impairments and other disabilities

To qualify for a radio the applicant must meet one of the following eligibility criteria:

Be certified as legally blind

Have only partial vision, requiring the use of visual aids other than ordinary eyeglasses in order to read conventional print comfortably

Have a physical disability that prevents normal reading because of an inability to hold printed material

Have any type of reading disability

If the applicant meets any one of the above criteria, he or she is eligible for the service of Virginia Voice. Please completely fill in the application form and return it to Virginia Voice at the address indicated.

Upon our receipt of the application, a Virginia Voice radio will be provided to the applicant. The radio will be issued on a loan basis, at no charge, for as long as the applicant needs the service.

Although there is no charge for the use of the radio, annual contributions are encouraged. Virginia Voice is a non-profit organization, and all contributions are tax-deductible to the extent allowed by law.

It is imperative that Virginia Voice be notified of any change of address or phone number. The radio is to be returned to Virginia Voice if the listener moves outside of the Greater Richmond area. Our radios are tuned to only one frequency and, therefore, will not function outside of the Greater Richmond area.

Application

Applicant Information Required:

Birth date
Name with prefix (Mr. Mrs. Ms. Miss), First, Middle Initial and Last name
Street address
City
County
State
Zip
Email address
Home Phone Number
Name under which home phone is listed
Relationship to Applicant
Cell Phone
Work Phone

How did applicant learn of this service?
Applicant Employed By or Retired From:

Nearest Relative or Close Friend (may be at same address as applicant)
Name with prefix (Mr. Mrs. Ms. Miss), First, Middle Initial, Last Name
Relationship to applicant
Email address
Home Phone
Cell Phone
Work Phone
Street address
City
State
Zip

Another Relative or Friend (not at same address)
Name with prefix (Mr. Mrs. Ms. Miss) First, Middle Initial, Last Name
Relationship to applicant
Phone
Email address
Home Phone
Cell Phone
Work Phone
Street address
City
State
Zip

Eligibility:

The above-named applicant is eligible for a Virginia Voice radio for the following reason(s) :

Vision Impairment (Please Explain):

Other Disability or Condition (Please Explain):

Return to: Virginia Voice
P.O. Box 15546
Richmond, VA 23227

Phone: (804) 266-2477
Fax: (804) 266-2478

Printable Application for a Virginia Voice Radio