Annual Student List

To be completed by Certifying Authority of Public or Private School

Please provide information on the students unable to use standard printed materials that will receive library service at your school during the current school year.

Please return this form to the Library for the Blind and Physically Handicapped, State Library of North Carolina, 1841 Capital Boulevard, Raleigh, North Carolina, 27635.

Name of school: _____________________________________    City: ________________________

School year: ________ - ___________


List qualifying students here
Student name Qualifying disability Date of birth Current grade Reading level

Qualifications for certifying authority are given on page four of the application.   Please note that schools requesting service for students eligible for service due to a reading disability must have completed, for each student, a separate individual application that includes medical doctor certification.  Individual applications and additional information are available by calling our toll-free number, 1-888-388-2460.


__________________________________________                     _________________________________

                (Signature)                                                                                                              (Date)

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