Early Explorers Registration

2012 Early Explorers Registration

I wish to register for the Early Explorers Program. I understand this is an early O&M program for blind and low vision babies, toddlers, preschoolers, and young children. This program is for children ages seven or younger, and the child that I am registering is currently within this age range.

Note: This program is only open to children living in the United States and Canada.

All fields marked with an asterisk(*) are required.

First name of person completing this form *

Last name of person completing this form *

Please select your relationship to the child *

If you answered other, please describe your relationship with the child.

E-mail *

Your Preferred Contact Phone Number(s).

Home Phone

Work Phone

Cell Phone

Participating Child's Information.

Child's First Name *

Child's Last Name *

Child's Date of Birth*

Month

Day

Year

Child's Height

Feet *

Inches *

Child's Address

Address 1 *

Address 2

City *

State *

Zip Code *

Does child currently use a cane? *

If yes, how long has child been using a cane?

Child's Gender

Child's Race

If other, please specify.

Does the child have any additional impairments that may impact his or her learning? If so, please check all that apply.

If other, please specify.

Is the child a Braille reader? *

How did you hear about this program? *

If other, please specify.

Future Reflections is a magazine for parents and teachers of blind children. It is published quarterly by the American Action Fund for Blind Children and Adults in partnership with the National Organization of Parents of Blind Children.
Future Reflections is free of charge to subscriber addresses in the United States in regular print, cassettes, e-mail or online at www.nfb.org.
Canadian subscriptions are $35 per year.

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2012 Early Explorers Registration

Your Preferred Contact Phone Number(s).

Participating Child's Information.