the Center - Lending Library Application

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Complete this online application. Upon submitting, you will receive an electronic copy via email. Print, sign, scan, and email the form to your regional KSD Outreach consultant or to Tony.Peavler@ksd.kyschools.us , or use the QR code on the form to upload an image or scan of the document from your handheld device.

Email *

Applicant First Name *

Applicant Last Name *

Home Street Address *

Home City *

Home State *

Home ZIP *

Personal Phone *

Is this a cell? *

Yes

Role *

Parent of child who is deaf/hard-of-hearing

D/HH Teacher

Interpreter

Community member

Other professional providing D/HH services (Describe below)

Other:

Other Professional Description

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