Request a cane Name(Required) First Last Address(Required) Street Address City ZIP / Postal Code State(Required)AlabamaAlaskaArizonaArkansasCaliforniaConnecticutColoradoDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces EuropeArmed Forces PacificCountrySelect 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 IslandsThis field is hidden when viewing the formCountySelect OneAdamsAlamosaArapahoeBacaBentBoulderBroomfieldChaffeeCheyenneClear CreekConejosCostillaCrowleyCusterDeltaDenverDoloresDouglasEagleEl PasoElbertFremontGarfieldGilpinGrandGunnisonHinsdaleHuerfanoJacksonJeffersonKiowaKit CarsonLa PlataLakeLarimerLas AnimasLincolnLoganMesaMineralMoffatMontezumaMontroseMorganOteroOurayParkPhillipsPitkinsProwersPuebloRio BlancoRio GrandeRouttSaguacheSan JuanSan MiguelSedgwickSummitTellerWashingtonWeldYumaOtherPhonePrimary Email Are you already a registered Aftersight listener? Yes No Unsure Eligibility RequirementAftersight services are intended solely for people who are blind, visually impaired, or print disabled. Vision Loss Yes No Other Barrier (Please Specify)Date of Birth Year Month Day Gender Male Female Non Binary/Third Gender Prefer Not to Say Identify as Transgender Cisgender Other Prefer not to Say This field is hidden when viewing the formRace/EthnicityRace/Ethnicity Hispanic/Latino American Indian Asian Black/African American Middle Eastern or North African Native Hawaiian/Pacific Islander White/Non-Hispanic Prefer not to answer 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 Describe 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 English Spanish (Español) Other What is your household size?Do you live in a female headed household? Yes No Prefer Not to Say Are you a veteran? Yes No What is your household Income?If you would rather not answer, please type “Would rather not answer”Do you have internet access? Yes No Unsure Do you have a smart phone? Yes No Unsure Alternate Contact Alternate Contact First Name Alternate Contact Last Name Alternate Contact PhoneAlternate Contact Email 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 Thumbdrive Website NotesAny other information you’d like us to know about you.Cane preferencesWe 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. If you have special requests, please contact us directly at penn@aftersight.org or 303-786-7777 Ex.4104 Select Cane Size(Required)Please double-check your size to help us streamline our processes and ensure your package arrives on time and in perfect condition. 242628303234363840424446485052545658606264666870 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.What is your height?(Inches)Select Cane Tip PreferenceNo preferenceMarshmallow TipMetal Glide TipRoller Ball TipNEW: Pathfinder 360How did you hear about Aftersight? Resource Fair Presentation Friend/Family Physician’s Office Service Provider Name of Friend/Family or OrganizationPlease write a name or business name of who told you about Aftersight.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 PoliciesIs 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! Would you like to donate to our cause?We are a nonprofit that depends on donations to stay thriving! If Aftersight is useful to you, please consider making a donation of $5, $20, $50, or whatever you can to help us continue this service. Yes, I would like to add a donation to this form. Donation 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 FormatAftersight 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 formRegionThis field is hidden when viewing the formJoin our 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! Please ensure you have answered all required questions! Upon clicking “submit”, please stay on this page until it completes the submission. Once it completes, please scroll down to ensure it was submitted successfully.EmailThis field is for validation purposes and should be left unchanged. Δ
