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National Association for Parents of Children with Visual Impairments (NAPVI)

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We hope to someday have online membership, but until then you simply need to print out this form, fill it in, and mail it to the address below.

I am applying for membership as (check one):
 

_____  Parent/Guardian ($40.00/year)
_____  Agency or Community Group ($250.00/year)
_____  Professional ($50.00/year)

  Parent/Guardian Membership includes membership in your local State chapter of NAPVI.
Membership assistance for parents and guardians is available upon request
.
 

Name: _____________________________________________
Agency: _____________________________________________
Address: _____________________________________________
City: _______________________ State:_____ Zip:________
Telephone (home) (____)____________________
(work) (____)____________________
E-Mail: ____________________________
Fax: ______________________________

Legislative District: _______________________________________________________

Please give additional information about your child(ren) with visual impairment:

Name:
______________________
Birth date: __________Gender:_____
Eye condition: ______________________ Other Disability:
__________________________

I give NAPVI permission to release this information to other parents.

_____Yes _____ No

Would you be interested in NAPVI materials in Spanish?

_____ Yes _____ No

 

Enclosed is payment for my dues in the amount of $ __________
Also enclosed is my tax deductable gift for the Endowment Fund: $ __________
Grandparent Membership ($20.00) - give address below $ __________

Total amount enclosed:

$ __________

 
 

Grandparent Membership information
Name: _____________________________________________
Address: _____________________________________________
City: ______________________ State:_____ Zip:________
Telephone (home) (____)____________________
(work) (____)_______________________________
Email: _____________________________________
Fax: _____________________________________

Print form, fill-in, and mail (with your check payable to NAPVI) to:

NAPVI
P.O. Box 317
Watertown, MA 02471

 

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