3rd Annual Be OK with Blindness

Provide your full name (first, last). If you are a parent/guardian, we encourage both parent/guardian(s) to attend, if possible.

Please indicate your relationship to the blind/low vision child with whom you are accompanying to Be OK with Blindness:

Parent Guardian Family Member Teacher Para-professional Administrator (school) Rehabilitation Counselor School Counselor Other

Mailing Address

City

State

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

ZIP Code

Email address

Home Phone:

Cell Phone

Please provide the requested information for all children (3 months - 24 years) who will be attending

Participant #1 Name (first, last)

Participant #1 Age

Participant #1 is:

Blind/low vision Sighted sibling Sighted family member Blind/low vision family member

Any special considerations that we should be aware of? If yes, please provide details

Participant #2 Name (first, last)

Participant #2 Age

Participant #2 is:

Blind/low vision Sighted sibling Sighted family member Blind/low vision family member

Any special considerations that we should be aware of? If yes, please provide details

Participant #3 Name (first, last)

Participant # 3 Age

Participant #3 is:

Blind/low vision Sighted sibling Sighted family member Blind/low vision family member

Any special considerations that we should be aware of? If yes, please provide details

Participant #4 Name (first, last)

Participant #4 Age:

Participant #4 is:

Blind/low vision Sighted sibling Sighted family member Blind/low vision family member

Any special considerations that we should be aware of? If yes, please provide details

Participant #5 Name (first,last)

Participant #5 Age:

Participant #5 is:

Blind/low vision Sighted sibling Sighted family member Blind/low vision family member

Any special considerations that we should be aware of? If yes, please provide details

Request for childcare (for children 3 months to 7 years)?

Yes No

Name of parent/responsible adults who are allowed to pick up child from childcare room (No more than 2 Names)

1. Name (first, last)

Home phone:

Cell phone:

Email:

2. Name (first, last)

Home Phone:

Cell phone:

Email: