Required field(s) are indicated by an *. STUDENT AND PARENT/GUARDIAN PROFILE * Student First Name * Student Last Name * Birth date 01 January 02 February 03 March 04 April 05 May 06 June 07 July 08 August 09 September 10 October 11 November 12 December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 2045 2046 2047 2048 2049 2050 2051 2052 2053 2054 2055 2056 2057 2058 2059 2060 2061 2062 2063 2064 2065 2066 2067 2068 2069 2070 2071 2072 2073 2074 2075 2076 2077 2078 2079 2080 2081 2082 2083 2084 2085 2086 2087 2088 2089 2090 2091 2092 2093 2094 2095 2096 2097 2098 2099 2100 2101 2102 2103 2104 2105 2106 2107 2108 2109 2110 * Gender Female Male Please choose the student's grade level as of January 2010. * Grade 5th 6th 7th 8th 9th 10th * Parent/Guardian First Name * Parent/Guardian Last Name * Relationship to the Student * Address Address 2 * City * State Select a State Outside United States Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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 Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming * Zip Code Please provide a valid e-mail address where we can send updated information to you regarding the program. A confirmation e-mail will also be sent to the e-mail address provided once you submit your application. * E-mail Home Phone Work Phone Cell Phone Please clearly tell us about any medical conditions or disabilities the child has, including cause of blindness, visual functioning (if any), medications that will need to be taken during the session, and any other special considerations (medical or otherwise) of which we need to be aware. * Medical Information
Describe your child's academic performance. Please include a list of all strengths and weaknesses, as well as GPA and any other relevant information. * Academic Performance
Describe any technology that your child uses, as well as his/her reading medium (print, Braille, both). * Technology/Reading
Please describe your child's level of independence and maturity in the following areas (as relevant to his/her age): * Mobility
* Social Skills
* Table Manners
* Hygiene
* Health Care
CHAPERONE PROFILE: Please enter the name of the parent, teacher, or mentor who will accompany the child to the LAW Program. If the contact information (address, phone numbers, and e-mail) of the Chaperone is the same as the Parent/Guardian information this is not required. * Chaperone First Name * Chaperone Last Name * Birth date 01 January 02 February 03 March 04 April 05 May 06 June 07 July 08 August 09 September 10 October 11 November 12 December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 2045 2046 2047 2048 2049 2050 2051 2052 2053 2054 2055 2056 2057 2058 2059 2060 2061 2062 2063 2064 2065 2066 2067 2068 2069 2070 2071 2072 2073 2074 2075 2076 2077 2078 2079 2080 2081 2082 2083 2084 2085 2086 2087 2088 2089 2090 2091 2092 2093 2094 2095 2096 2097 2098 2099 2100 2101 2102 2103 2104 2105 2106 2107 2108 2109 2110 * Gender Female Male Address Address 2 City State Select a State Outside United States Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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 Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming Zip Code Please provide at least one valid contact phone number for the Chaperone. Home Phone Work Phone Cell Phone Please provide a valid contact e-mail address for the attending Chaperone if applicable. Chaperone E-mail Address Occupation of attending adult * Chaperone's Occupation What is the Chaperone's relationship to the Student? * Relationship to Student If the Chaperone is a teacher of the blind/visually impaired, please complete the following fields: Name of school or district for which the teacher is employed School's Address Address 2 City State Select a State Outside United States Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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 Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming Zip Code School Phone Number Please clearly tell us about any special considerations (medical or otherwise) of which we need to be aware regarding the adult accompanying the child. Additional Chaperone Information
Does the student's family receive Future Reflections? * Future Reflections Yes, We receive Future Reflections No, Please register us No, Not interested If the accompanying adult is a teacher of the blind/low vision, does he/she receive Future Reflections? * Teacher Future Reflections Yes, They receive Future Reflections No, They wish to be registered No, They are not interested 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 available free of charge to subscriber addresses in the U.S. in regular print, 4-track cassette, via e-mail, or online on the NFB Web site (see below on this page). Starting January 2010, Canadian subscriptions are $35 per year, and foreign subscriptions are $75 USD per year. Checks should be made payable to the National Federation of the Blind and sent to the NFB, attention Future Reflections, 200 East Wells Street, Baltimore, Maryland 21230.
