Spinal Cord Injury Video Access is a program in which informational videotapes are lent through the mail to individuals with spinal cord injury and their families. Some of the topics covered by the videotapes are accessibility, health, housing, sports, sexuality, and travel.
A one-time $25.00 refundable deposit is necessary in order to participate in the Spinal Cord Injury Video Access program. This helps to remind people to return the videotape(s). Video lending policy requires a survey be completed for each video viewed.
No postage is necessary to return the videotape and survey if mailed in the same envelope in which you received the video. Spinal Cord Injury Video Access provides a return label. Place the label on the envelope and seal the package. Place the package in the mailbox or give to your postal carrier. Each borrower has 14 working days to return the videotape.
Your donations and membership help keep the program operating. We would like each borrower to become a member of Spinal Cord Injury Network International. The yearly membership fee is $20. Thank you for supporting our progams and services.
You may submit your form online, or complete the form online, print it, and mail or FAX (707-577-0605 ) it to SCINI. You may select a tape from our videotape catalog once we have received your Video Registration Form/Statement of Deposit and your $25.00 refundable deposit.
Please make check payable to SCINI and send to: Spinal Cord Injury Network International Attn: Spinal Cord Video Access 3911 Princeton Drive Santa Rosa, CA 95405-7013 Questions? Contact us at the address above; call us at 1-800-548-CORD (1-800-548-2673); or e-mail us at spinal@sonic.net
Name (use format: Last, First):
ID# or Driver's License #:
Street Address:
City:
State:
Zip Code:
Area Code/Phone:
Social Security No.:
Date of Injury:
Level of Injury:
Cause of Injury:
Rehab Hospital:
Disability:
Enclosed is my $25 refundable deposit, which will be returned to me when I so request. I agree to handle the videotapes I borrow with care, and to return the videotapes by the date requested. I will be responsible for replacement costs should the videotape be damaged or lost while in my care. A check returned because of insufficient funds is subject to a $10 fee.
Signature
Date
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