1 Current Page 1 2 Preview Personal information on this form is collected under Section 31(c) of the Freedom of Information and Protection of Privacy Act and will be only for the purpose of providing library services. Questions regarding the collection and use of this information can be directed to the Director of Libraries & Archives at P.O. Box 2000 Charlottetown, PE C1A 7N8. Identification Enter information for the participant who will be recieving the service. First Name Middle Initial Last Name Address 1 Address 2 City, Town, or Community Province Postal Code For example: C1B 0X1 or 12345 Country Telephone Number For example 902-555-5555 Email Address Name of a Parent or Legal Guardian if Applicant is 15 Years or Younger Accessible Services Information (choose all that apply) Delivery by mail of DAISY audiobook CDs from Public Library Service Headquarters Access to a DAISY audiobook player Access to CELA (Centre for Equitable Library Acccess) and its collection of materials in digital and physical alternate formats Caregiver/Designate Information Only complete this section if you are applying on behalf of the person receiving the services. First Name Middle Initial Last Name Telephone Number For example 902-555-5555 Email Address Acceptance I acknowledge that I have a perceptual disability as defined under the Canadian Copyright Act and that I may be called upon to provide proof of such disability from a competent authority. Competent authority is defined to include doctors of medicine, ophthalmologists, optometrists, registered nurses, registered therapists, professional staff of hospitals, institutions and public agencies (e.g. vision rehabilitation specialist, social workers, case workers, counsellors, teachers and school district superintendents). A CNIB client number will be accepted as a competent authority. Library materials restricted to people with print disabilities (eg DAISY talking books) are for my personal use only. I will not copy, share or redistribute these materials. I agree to the disclaimers.