Future Reflections Convention, 2002
Completed form and fees must be received on or before June 15, 2003
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 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 is unable to care for our child(ren), further access to childcare will be denied.
Parents Signature __________________________________ Date _______________
Make checks
payable to NFB Cam
Return form to
National Federation of the Blind of Oregon
5005 Main Street,
Springfield, Oregon 97478, (541) 726-6924