Listener Data Form
WJCT Radio Reading Service (RRS)
RRS Listener FIRST Name:
RRS Listener LAST Name:
Facility Name (if applicable):
Best Phone to Contact You:
Date of Birth (Year):
Are you a veteran?
Please check one of the following. I live:
(KEY: A=Alone; H=As a member of a household; F=In an assisted living/nursing home/other facility) O=Other (Specify)
I am unable to read ordinary print materials due to the following condition(s)...Please check all that apply:
(KEY: 1=Legally Blind; 2=Partial//Declining Vision; 3=Reading Disability; 4=Physical Challenge(s) 5=Macular Degeneration 6=Other (specify)
How did you hear about RRS?
Please check one of the following statements:
I prefer to listen to the RRS via the internet and will NOT require a special radio receiver from WJCT.
I prefer to listen to the RRS on a special radio receiver provided by WJCT, on loan and free of charge. Please send it to me at my address provided above.
FOR LISTENERS WHO ARE REQUESTING A SPECIAL RADIO RECEIVER:
Please provide the name of a friend, relative, or caregiver who will be the contact person who agrees to return the radio receiver if you are not able to return it on your own.
My Name (Listener):
My Contact's Name:
Contact's relationship to above Listener:
Contact's Street Address, City, State and Zip Code
Contact's Phone Number:
(For Listeners requesting a special radio receiver, please agree to the following terms):
1. The RRS receiver will only be used by someone unable to access print.
2. The RRS receiver is being lent to me free of charge.
3. If I move from Northeast Florida or Southeast Georgia, or can no longer use the service, I, or my contact person listed above, will arrange to have the unit sent back to WJCT at 100 Festival Park Ave, Jacksonville, FL. 32202. (The radio does not get reception outside of this geographic area.)
4. The receiver cannot be given to another individual and is the property of the WJCT RRS.
5. I, or my contact person, will inform the RRS of any change in address, phone numbers and email so that we can keep our listener data base up to date.
Yes, I understand and agree to these terms.
I understand and agree
WJCT collects the information below in order to apply for grants in support of the RRS. Providing information for the next three questions is optional.
Origin (check one):
Race (check one):
American Indian/Alaska Native
Native Hawaiian/Other Pacific Islander
Annual Income (check one):
(KEY: 1=$0-$26,999; 2=$27,000-$49,999; 3=$50,000 and above)
Support the Radio Reading Service
WJCT Radio Reading Service is a non-profit service that depends solely on donations to operate. A donation is appreciated, but inability to contribute will not affect your eligibility to access the RRS. If you enjoy our service, please encourage friends and family to offer financial support. This tax-deductible gift will provide news, information, entertainment, and cultural opportunities to community members who are visually impaired and print-challenged.
Here's how to make an online contribution to the RRS: After you submit this data form by clicking the blue "Submit" button below, return to the top of the page and hit the yellow "Support WJCT" button, which will take you to the page where you can give to the Radio Reading Service specifically.
Make tax-deductible donations to:
WJCT Radio Reading Service
100 Festival Park Avenue
Jacksonville, FL 32202
Never submit passwords through Google Forms.
This form was created inside of WJCT Public Broadcasting.
Terms of Service