|
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.
Would you be interested in NAPVI materials in Spanish?
| 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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