Application for Service

I am applying for: (Choose all you're interested in.) *Dial-in ServiceRadio Reading ServiceMobility and White Cane TrainingBraille InstructionTechnology TrainingMen’s Support GroupAudio Description

Where did you learn about Metropolitan Washington Ear?

Vision StatusBlindLow Vision

Do you need wheelchair access?YesNo

First and Last name *

Email Address *

Confirm Email Address *

Primary Phone *

Mobile/Cell phone

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

I reside in: *Washington, DCMarylandVirginia

Birth Date *

Living ArrangementLive aloneMember of householdAt schoolAt nursing home or retirement home

Name of home, if applicable

Please provide alternate contact info in the event we cannot reach you, for equipment maintenance or recovery. *

Choose the media type of instructions for using the services. *TapeLarge PrintEmailmp3 audio

Consent *I certify that I have read the Agreement for Dial-in Service and/or the Agreement for Radio Reading Service and agree to their terms.

Upload Certificate of Disability (or mail to MWE)

No file chosen

When arriving at our office, will you be taking MetroAccess? *YesNo

If you may be arriving late, please call 301-681-6636. Also, provide cell phone number where we can reach you.

Notes: Anything else you would like us to know?

Application for
Dial-in and/or Radio Reading Service

Online Application

Application for Service

Application for Dial-in and/or Radio Reading Service

Online Application

Application for
Dial-in and/or Radio Reading Service