White Cane Form - Aftersight

Apply to become an AINC Listener, receive free equipment, and more!

Comments

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Aftersight Options

What would you like to do?(Required)

Select all that apply

Become an Aftersight Listener

Request a Free Cane

Join Low Vision Support Group

Join Audio Book Club

Contact Information

Name(Required)

First Middle Last

Nickname

Date of Birth(Required)

Year

Month

Day

Age

Address(Required)

Street Address City ZIP

State

County

Location

Senior living community name

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County

Phone

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Other Phone

Email(Required)

Enter Email Confirm Email

Alternate Contact

Alternate Contact First Name Alternate Contact Last Name

Alternate Contact Phone

Alternate Contact Email

Eligibility Requirement

Aftersight services are intended solely for people who are blind, have low vision, or need an alternative to print.

Eligibility(Required)

Vision Loss

Need Alternative to Print

Other

Other Barrier (Please Specify)

Demographic Information

We ask for demographic information to meet the requirements of our funders. All your personal information is confidential.

Gender(Required)

Male

Female

Cisgender

Transgender

Non Binary

Prefer Not to Say

Gender not listed

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Race/Ethnicity

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Race

Hispanic/Latino

American Indian or Alaska native

Asian or Asian American

Black or African American

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White/Non-Hispanic

Prefer Not to Say

Other

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What do you identify as?

American Indian

Asian

Black/African American

Hispanic/Latino

Native Hawaiian/Pacific Islander

White/Non-Hispanic

Prefer not to answer

Other

Race not listed

Describe your race/ethnicity

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What do you identify as?

American Indian

Asian

Black/African American

Hispanic/Latino

Native Hawaiian/Pacific Islander

White, non-Hispanic

Other

Prefer not to answer

Preferred Language(Required)

English

Spanish (Español)

Other

Specify other preferred language

Do you have internet access?

Yes

Do you live in a female headed household?

Yes

Prefer Not to Say

Are you a veteran?

Yes

Active Duty

Number of people in your household(Required)

Including you. Enter “1” if you live alone.

What is your household income?

Less than $14,580

$14,580 – $24,650

$24,650 – $41,050

$41,050 – $62,600

More than $62,600

What is your household income?

Less than $19,720

$19,720 – $28,150

$28,150 – $46,900

$46,900 – $71,550

More than $71,550

What is your household Income?

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Do you have a smart phone?

Yes

Unsure

How did you hear about Aftersight?

Resource Fair

Presentation

Friend/Family

Physician’s Office

Service Provider

Other

Name of Friend/Family or Organization

Please write a name or business name of who told you about Aftersight.

Communication Preference

Large Print

Braille

Notes

Any other information you’d like us to know about you.

White Cane Request

Aftersight provides Awarewolf Urban Explorer canes with a standard hook-on marshmallow tip. An individual may request one cane per year.

Awarewolf Cane:

Sleek, durable, and purpose-built for urban environments, the Urban Xplorer sets a new standard for what a city cane should be. Reinforced for strength. Balanced for comfort. Designed to keep up with real life.

How to measure cane size

Cane size typically depends on your height and how fast you are. If you tend to walk fast, measure from the ground to your nose. If you tend to walk slow, measure from the ground to your sternum. If you are in between, measure from the ground to your chin.

Select a Cane Size

What is your height in inches?

Are you already an Aftersight Listener

Yes

Unsure

Want to get more involved?

Join Support Group

Low-Vision Support Group

Join Book Club

Join Audio Book Club

Mailing List

We would like to send occasional news from Aftersight. To join our emailing list, simply check the box below. You can unsubscribe at any time.

Add me to your mailing list

Thanks to a kind gesture, Aftersight's services are available to you without any charge. Will you extend that same kindness to the next person?

Every time you benefit from Aftersight’s services, remember this: it’s available to you at no cost because someone before you generously donated. They chose to make a difference, to ensure that the next person, perhaps someone like you, has the same access and opportunities. Now, it’s your chance to continue this chain of kindness. By donating — be it $5, $20, $50, or any amount — you’re not just giving money. You’re giving another individual the gift of accessibility, of knowledge, of connection.

Yes, I’d like to pass on the gift with a donation.

Add a gift

Donation amount

Please enter the dollar amount you’d like to contribute.

Total

This page is unsecured. Do not enter a real credit card number! Use this field only for testing purposes.

Credit Card

Card Details

Cardholder Name

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Program Schedule Format

AINC regularly mails out programming schedules and other information. There are several formats that we can send information in.

Large print

Braille

Thumbdrive

Website

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Equipment Type

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Equipment ID

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Region

Consent

General Policy Consent(Required)

Aftersight’s Privacy Policy, Contribution Policy, and Grievance Policy are available at aftersight.org/policies-and-documents. If you would like these policies sent to you, please call Aftersight at 303-786-7777.

I agree to Aftersight Policies

Is the information provided accurate and true?(Required)

Yes, I certify that the information submitted with this form is accurate and true.