Listener Application

Contact Information

Name of applicant*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

County

Do you live in a shared living community?*

Yes
No

What is the name of the shared living community you live in?

Phone

Email

Eligibility Requirement

Broadcasts are intended solely for people who have vision loss (blind/visually impaired) or have other limitations which prevent reading standard size print materials (print disabled).

Does the applicant experience vision loss?

Yes
No

Does applicant experience another barrier to reading? If yes, please specify in the text box below.

Demographic Information

Funding agencies ask for data on who we serve. AINC provides summaries of this anonymous data only to authorized funders.

Age:*

Please enter a number from 0 to 150.

Sex:

Male
Female

Date of Birth*

MM

DD

YYYY

With which ethnic group does applicant most identify as?

Check all that apply.

American Indian or Alaskan Native
Native Hawaiian or Pacific Islander
Caucasian / White
Asian
Black / African American
Hispanic
I would rather not say.

What is applicant's preferred listening language?

Spanish
English

What is the applicants living situation?

Live alone
With family and/or friend(s)
Assisted Living Facility in a shared room (Roommate)
Assisted Living Facility in a non-shared room (No roommate)
I would rather not say.

Does applicant live in a female headed household? Is applicant a U.S. Service Veteran?*

Select all that apply.

Female headed household
U.S. Service Veteran
None of these apply
I would rather not say.

How did you hear about the Audio Information Network of Colorado?

What is the applicant's monthly household income range?

Does applicant have internet access at home?

Yes
No
I'm not sure.

Which listening options are you most interested in?*

AINC Amazon Echo smart speaker and/or tablet
Internet through your personal computer, smart phone, or smart speaker
AINC WiFi Radio for audio broadcast
AINC pre-tuned digital reciever
AINC Large Button speakerphone
Call in using your personal telephone
I'm not sure.

Which listening options are you most interested in?

AINC pre-tuned digital reciever
AINC Large Button speakerphone
Call in using your personal telephone
I'm not sure.

What format would applicant like the program schedule in?

Programming schedules and other information may be sent to you periodically. We have several formats that we can send information in. Select all of the formats that are acceptable to you.

Large print
Braille
Audio CD or flashdrive
Online at website
I'm not sure.

Are you an agency representative or caregiver completing this form for someone else?

I am filling this out for someone else
I am filling this out for myself

Your name

Person filling out form

First Last

Name of Agency

Your phone number

Person filling out form

AINC's Privacy Policy, Contribution Policy, and Grievance Policy

are available at aincolorado.org/policies-and-documents/

Would you like a copy of these policies mailed to you?

Yes
No

Email

This field is for validation purposes and should be left unchanged.