Listener Application

En español

Sign up Today

Are you blind, have low vision, or need an alternative to print?

Contact Information

Name(Required)

First Middle Last

Nickname

Date of Birth(Required)

Year

Month

Day

Age

Address(Required)

Street Address City ZIP

State

County

Country

Location

Senior living community name

This field is hidden when viewing the form

County

Home Phone

Mobile Phone

This field is hidden when viewing the form

Other Phone

Eligibility Requirement

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

Vision Loss

Yes

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

Non Binary/Third Gender

Agender/Don’t Identify with any gender

Prefer Not to Say

Gender

Identify as

Cisgender

Transgender

Nonbinary

Other

Prefer not to Say

Gender not listed

This field is hidden when viewing the form

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

This field is hidden when viewing the form

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

This field is hidden when viewing the form

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

English

Spanish (Español)

Other

Specify other preferred language

¿Prefieres una forma en español?

Haga clic aquí

Do you have internet access?

Yes

Unsure

Do you live in a female headed household?

Yes

Not Sure

Prefer Not to Say

Are you a veteran?

Yes

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?

This field is hidden when viewing the form

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.

Alternate Contact

Alternate Contact First Name Alternate Contact Last Name

Alternate Contact Phone

Alternate Contact Email

Program Schedule Format

Aftersight regularly mails out programming schedules and other information. There are several formats that we can send information in. Which one do you prefer?

Large Print

Braille

Thumbdrive

Website

Notes

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

General Policy Consent(Required)

Aftersight’s Privacy Policy, Contribution Policy, Echo Consent 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.

Want to get more involved?

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

Credit Card

Card Details

Cardholder Name

This field is hidden when viewing the form

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

This field is hidden when viewing the form

Equipment Type

This field is hidden when viewing the form

Equipment ID

This field is hidden when viewing the form

Region

This field is hidden when viewing the form

Join our mailing list.

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

Add me to your mailing list!

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

Learn more about Aftersight

Prefer a paper application? Print this version and send to 1700 55th st., Suite A, Boulder, CO, 80301.

Printable Form

View Our Policies

NOTICE TO Aftersight VOLUNTEERS: Do not fill out this form. If you need assistance, please contact the Volunteer Coordinator.