Future Reflections Spring/Summer 2004
NFB Camp Registration Form
Parent’s Name____________________________________________________________
Address ________________________________________________________________
City _____________________ State ________ Zip ________ Phone ________________
Child(ren)’s Name(s)
______________________________________________Date of Birth _________ Age
______________________________________________Date of Birth _________ Age
______________________________________________Date of Birth _________ Age
Include description of any disabilities/allergies we should know about: ______________ ________________________________________________________________________________________________________________________________________________
Who, other than parents, is allowed to pick up your child? _________________________ ________________________________________________________________________
Per Week: $80 first child; $60 siblings # of children _____ $ ________
(Does not include banquet)
Per Day: $20 per child per day # days ____ x $20/child $ ________
(Does not include banquet)
Banquet: $15 per child # of children _____ x $15 $ ________
Total Due $ ________
We understand that NFB Camp is being provided as a service by the NFB to make our convention more enjoyable for both parents and children. We understand the rules we were given and agree to abide by them. We will pick up children immediately following sessions. We understand that if our child(ren) does not follow the rules or if for any reason staff are unable to care for our child(ren), further access to childcare will be denied.
Parent’s Signature __________________________________ Date ____________
Make checks
payable to NFB Camp.
Return form to National
Federation of the Blind of Oregon
5005 Main Street,
Springfield, OR 97478, (541) 726-6924.