Mission for the Visually Impaired Service Application

A field marked with a red asterisk is required.

Who is submitting this application?*

I am submitting my own information.
I am submitting information for someone else.

Contact Information

If you are submitting information for someone else, we may need to ask you for more information. Please provide us with your contact information.

Name*

First Last

E-mail*

Enter e-mail Confirm e-mail

Phone

Is the person you are referring a European Union (EU) resident?*

Yes
No

European Union (EU) laws require that organizations may not contact EU residents without the resident’s permission. EU residents may request our materials directly by contacting Mission for the Visually Impaired at [email protected]

Personal Information

Name of person who is visually impaired or print impaired*

First Middle Last Suffix

Address*

Address line 1 Address line 2 City State/Province Zip/Postal code Country

E-mail*

Enter e-mail Confirm e-mail

E-mail

Enter e-mail Confirm e-mail

Phone*

Which of these kinds of resources can this person use? (select all that apply)*

Select All
Audiobook
Braille
Large print

Is this person visually impaired or print impaired?*

Print impaired
Visually impaired

Church Information

WELS Special Ministries assists local congregations in serving their members and wishes to keep the church informed of our contacts with their members. Please provide information regarding the church of which this person is a member, if any.

Pastor's name

Church name

City

State/Province

Data Privacy & Permission*

I AGREE with the terms of the WELS Privacy Policy.

NOTE TO EU CITIZENS, RESIDENTS, TOURISTS, AND OTHER PERSONS TEMPORARILY IN THE EU:

By submitting this form you consent to any and all information you provide and submit via the site being sent to the United States of America. The United States has not sought nor received a finding of “adequacy” from the European Union under Article 45 of the GDPR. WELS relies on derogations for specific situations as set forth in Article 49 of the GDPR. You are also informed that the United States presently does not have an adequate level of personal data protection as determined by the European Commission’s adequacy decision on October 6, 2015 (case c-362/14) and articulated in the European Union’s General Data Protection Regulation and has not received a similar designation of adequacy by any other foreign data protection authority. You agree to the transfer of your data and personal data to the United States, however, to be used in accordance with WELS Privacy Policy.

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