Courage Handiham System 
3915 Golden Valley Road 
Golden Valley, MN 55422 
Phone: (763) 520-0512 
e-mail: hamradio@couragecenter.org 
Website:http://www.handiham.org

 COURAGE HANDIHAM SYSTEM MEMBERSHIP APPLICATION 
(Individuals with disabilities only)

Name:  
Title: (Dr., Ms., Mrs., etc.)
Callsign (if licensed):
License Class (if licensed):
Address: 
City:
State: 
Postal Code:
Country:                                                                       
County (if USA): 
Home Phone:
Work Phone:
Your E-mail Address:
I would like to receive the free weekly Handiham e-mail newsletter. (Yes or No)
Please contact me via email with a Members-Only password, so that I can access audio and other files on the Handiham website. (You must have a computer and valid e-mail address)  (Yes or No)
My e-mail address: 
Password desired: (must be in all lower case)
I would like to receive the monthly QST/WORLDRADIO/QCWA digests. I prefer the following format: (choose only one)
NLS digital cartridge by mail  (Yes or No)
If you said Yes to the NLS cartridge, please send us a blank cartridge in a free matter mailer. Be sure your address information is on it. 
Internet audio in the Members-Only section of the website  (Yes or No)

I have a computer with Internet and want to take an on-line course (free to Handiham members - choose one)
Technician 
General 
Extra 
Operating Skills

INFORMATION ABOUT YOU
Date of Birth: 
Sex:  Male or Female: 
Please describe your disability :
When were you first disabled? 
My educational background is: (State last level completed) 
Special field of study: 
 
ADAPTIVE DEVICES YOU USE:
Wheelchair 
Scooter 
Walker 
Respirator 
Service Dog 
Speech Board 
Hearing Aid 
Voice-Activated Computer 
Screen Reading Computer 
Electronic Magnifier 
Books on Tape 
Books on Computer Disk 
Head-stick 
Light Pointer 
Cane 
Speaking Device 
Other (Please specify) 
Do you use the above devices all the time or only part of the time? 

YOUR COMMUNICATIONS HOBBY GOALS: Please check all that apply:
I want to use voice communications. 
I want to learn more about short-wave radio.  
I want to communicate by using a keyboard. 
Talking around the world is one of my goals. 
Local radio contacts via repeaters using a hand-held radio are for me. 
The social fun of talking with others and making friends via radio is my goal.

FEES 
The annual membership fee (for members receiving services) is $12.00. 
Please make your check out to "Courage Handiham System."
$12.00 member fee enclosed; check or money order #
Please charge my Visa or Mastercard 
Card # 
Expiration: 

As a service to our members we can complete a membership application or renewal form for The American Radio Relay League (ARRL), which is a separate, unaffiliated national organization. Please include a check made out to "ARRL" in the proper amount if you would like to join or renew with the ARRL. 
I want to join/renew my ARRL membership - $8.00/year without QST magazine (blind members only) 
I want to join/renew my ARRL membership - $39.00/year with QST magazine (regular rate)  $36 age 65 + 
ARRL Membership Number (if renewing): 

OPTIONAL 
The following information is optional and is asked because public funding sources request statistical information on the racial mix of clients. Please check one: 
White, not of Hispanic origin 
Black, not of Hispanic origin 
Hispanic 
Asian or Pacific Islander 
Native American (Indian American or Native Alaskan)

If you are joining as a member with a disability, please sign below:
I wish to apply for a participating membership in the Courage Handiham System. I agree to abide by Handiham policies.

(Signature)                                                                                            
(Date Signed)