For Office Use Only:
PP# _________________
RE#_________________
Date_________________
Type ________________
ICD _________________
       
					
Courage Center Handiham System
3915 Golden Valley Road
Golden Valley, MN  55422
Phone:  (763) 520-0512 
hamradio@couragecenter.org 
http://www.handiham.org

COURAGE CENTER HANDIHAM SYSTEM 
MEMBERSHIP APPLICATION  
(Individuals with disabilities only)


Name __________________________________________________________________________________________
			(Last)				(First)				(Middle Initial)

Title________________ Callsign____________________  License Class (if licensed)_______________________
        (Dr., Ms., Mrs., etc.)

Address ________________________________________________________________________________________
     	  (Street, box number, apartment number, etc.)

City/State/Postal Code______________________________________________________________________________

Country___________________________________ County (if USA) _______________________________________

Home Phone ________________________________  Cell or Work Phone ___________________________________

Your e-mail Address ______________________________________________________________________________

( I would like to receive the free weekly Handiham e-mail newsletter.
( 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. Please specify a username & password or we will assign ones for you. Username is usually your callsign. Password must be in all lower case with an 8 character minimum.
       Username desired:____________________________  Password desired: ____________________________ 
( I have a computer with Internet and want to take an on-line course (free to Handiham members)   
        (Technician    (General    (Extra    (Operating Skills
The monthly Ham Radio Digest with articles from ham radio magazines is available in special audio format in the Members-Only section of the Handiham website. If you don't have Internet access and have a NLS digital player you may request them on NLS digital cartridge.  
(  I have a NLS digital player and will be sending you a blank cartridge and mailer. (see the NLS information page.)

INFORMATION ABOUT YOU

Date of Birth __________________________________	     Sex:    ( Male     (  Female

Please describe your disability ______________________________________________________________________

_______________________________________________________________________________________________

When were you first disabled? _______________________________________________________________________

My educational background is: 	(Circle last level completed)
	Grade 1    2    3    4    5    6    7    8    9    10    11    12    Trade School    Undergraduate Degree    Postgraduate

	Special field of study: _______________________________________________________________________

Please proceed to the next page.
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 use Morse Code.
(  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 is 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 Center Handiham System.”

(  $12.00 member fee enclosed; check or money order #____________________

(  Please charge my  (Visa	( Mastercard   ( Discover 
	Card # __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __	Expiration:  __ __ / __ __



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 Courage Center Handiham System.  I agree to abide by Handiham policies.




___________________________________________________________     ________________________________
  (Signature)									(Date Signed)

Revision 071712A