Survey - Application and Registration for Service - Friends of Public Radio Arizona

Application and Registration for Service

1. Biographical Information

Field Is Required First Name

Field Is Required Last Name

Field Is Required Date of Birth:

Field Is Required Street 1:

Field Is Required City/Town:

Field Is Required State / Province:

Field Is Required ZIP / Postal Code:

Email:

Field Is Required Phone Number:

If you respond and have not already registered, you will receive periodic updates and communications from Friends of Public Radio Arizona.

Keep me logged in. What's this?

2. Field Is Required Please complete the following information on race and ethnicity which will provide Sun Sounds of Arizona eligibility for federal funds.

3. Field Is Required Ethnicity (field required)

Hispanic/Latino
Non-Hispanic/Latino

4. Field Is Required What is your disability? (field required) Please make between 1 and 3 selections from the choices below.

Cognitive
Physical
Visual

5. Field Is Required Name of Verifying Authority (field required) (Maximum response 255 chars, approx. 5 rows of text)

6. Verifying Authority Phone Number

7. If you live in a facility. Facility Name and Number (Maximum response 255 chars, approx. 5 rows of text)

8. Field Is Required Service Requested (field required)

Please send me a Sun Sounds Radio
Please send me a Sun Sounds Amazon Echo Dot (Alexa)
I don't need a Radio or an Amazon Echo Dot. Please send a Large Print Schedule

9. If not listening via radio, I will listen via ... Please make between 1 and 3 selections from the choices below.

Online - website audio stream
Sero or TuneIn mobile app on phone or tablet
A Smart home device such as my own Google Home or my own Amazon Echo Dot (Alexa)

10. Program Schedule - Choose your preferred format (Please choose no more then 2 formats). Please make between 1 and 2 selections from the choices below.

Large Print
Audio CD
Braille
Email

11. How did you hear about Sun Sounds? - Please use the following field to tell us how you learned about Sun Sounds, or if you are a current listener registering with us.

This section applies to Sun Sounds Radio and Sun Sounds Amazon Echo Dot (Alexa) users. This is a Statement of Agreement and Responsibility.

Please understand that the Sun Sounds Radio receiver or Sun Sounds Amazon Echo Dot is on loan to you and remains the property of Sun Sounds. The Sun Sounds Radio or Sun Sounds Echo Dot will be returned to Sun Sounds when it is no longer in use.

Please provide a contact person not living with you. This person may be living outside of Arizona. They will only be contacted if your mail is returned and you have not notified Sun Sounds of your new address and phone number.

12. Field Is Required Contact Person's First & Last Name (field required) (Maximum response 255 chars, approx. 5 rows of text)

13. Field Is Required Contact Person's Telephone Number (field required) (Maximum response 255 chars, approx. 5 rows of text)

14. Field Is Required I have read the information furnished and will abide by the terms set forth by Sun Sounds of Arizona. Please enter your full name to agree to the above statement (field required) (Maximum response 255 chars, approx. 5 rows of text)

Services Available Statewide:

FLAGSTAFF: info@sunsounds.org
Phone: 480-774-8300

TEMPE: 2323 W. 14th St., Tempe AZ 85281
Phone: 480-774-8300, Fax: 480-774-8310

TUCSON: info@sunsounds.org
Phone: 480-774-8300

Arizona Braille and Talking Book Library: Arizona Braille and Talking Book Library will deliver library books and recorded material, as well as playback equipment, free of charge. They will contact you for more information. Sun Sounds of Arizona will not share or sell information on this application. The information will only be used as a referral to Arizona Braille and Talking Book Library where specified and requested.

15. Field Is Required Would you like a referral to the Arizona Braille and Talking Book Library? (field required)