Apply to become an AINC Listener, receive free equipment, and more! NameThis field is for validation purposes and should be left unchanged.Aftersight OptionsWhat 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 InformationName(Required) First Middle Last NicknameDate of Birth(Required) Year Month Day AgeAddress(Required) Street Address City ZIP StateSelect OneAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces EuropeArmed Forces PacificCountySelect OneAdams County, COAlamosa County, COArapahoe County, COBaca County, COBent County, COBoulder County, COBroomfield County, COChaffee County, COCheyenne County, COClear Creek County, COConejos County, COCostilla County, COCrowley County, COCuster County, CODelta County, CODenver County, CODolores County, CODouglas County, COEagle County, COEl Paso County, COElbert County, COFremont County, COGarfield County, COGilpin County, COGrand County, COGunnison County, COHinsdale County, COHuerfano County, COJackson County, COJefferson County, COKiowa County, COKit Carson County, COLa Plata County, COLake County, COLarimer County, COLas Animas County, COLincoln County, COLogan County, COMesa County, COMineral County, COMoffat County, COMontezuma County, COMontrose County, COMorgan County, COOtero County, COOuray County, COPark County, COPhillips County, COPitkins County, COProwers County, COPueblo County, CORio Blanco County, CORio Grande County, CORoutt County, COSaguache County, COSan Juan County, COSan Miguel County, COSedgwick County, COSummit County, COTeller County, COWashington County, COWeld County, COYuma County, COCountrySelect OneUnited States of AmericaCanadaAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsLocationSenior living community nameThis field is hidden when viewing the formCountyHome PhoneMobile PhoneThis field is hidden when viewing the formOther PhoneEmail(Required) Alternate Contact Alternate Contact First Name Alternate Contact Last Name Alternate Contact PhoneAlternate Contact Email Eligibility RequirementAftersight services are intended solely for people who are blind, have low vision, or need an alternative to print. Vision Loss(Required) Yes No Other Barrier (Please Specify)Demographic InformationWe 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 GenderIdentify as Cisgender Transgender Nonbinary Other Prefer not to Say Gender not listedThis field is hidden when viewing the formRace/EthnicityEthnicity 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 formWhat 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 listedDescribe your race/ethnicityThis field is hidden when viewing the formWhat 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 languageDo you have internet access? Yes No Unsure Do you live in a female headed household? Yes No Not Sure Prefer Not to Say Are you a veteran? Yes No 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 formDo you have a smart phone? Yes No Unsure How did you hear about Aftersight? Resource Fair Presentation Friend/Family Physician’s Office Service Provider Other Name of Friend/Family or OrganizationPlease write a name or business name of who told you about Aftersight.Program Schedule FormatAftersight 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 Website NotesAny other information you’d like us to know about you.White Cane RequestWe will try our best to get you a cane that is as close as possible to your preferences, however we are limited by what we have in stock so what you receive may not be exactly the size or tip you request. Our standard cane: Fiberglass Folding Standard red/white/black coloration. 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. If you have special requests, please contact us directly at penn@aftersight.org or 303-786-7777 Ex.4104 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 Type Standard Cane AwareWolf Select an AwareWolf Cane SizeSmall 43" – 49"Medium 48" – 54"Large 53"-59"XLarge 58" – 64"Select a Cane Size(Required)242628303234363840424446485052545658606264666870Select Cane Tip PreferenceNo preferenceMarshmallow TipMetal Glide TipRoller Ball TipNEW: Pathfinder 360What is your height in inches?Are you already an Aftersight Listener Yes No Unsure Want to get more involved?Join Support Group Low-Vision Support Group Join Book Club Join Audio Book Club Mailing ListWe 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 giftDonation amountPlease enter the dollar amount you’d like to contribute. Total Credit CardCard Details Cardholder Name This field is hidden when viewing the formProgram Schedule FormatAINC 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 formEquipment TypeThis field is hidden when viewing the formEquipment IDThis field is hidden when viewing the formRegionConsentGeneral 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 PoliciesIs the information provided accurate and true?(Required) Yes, I certify that the information submitted with this form is accurate and true. Δ
