Future Reflections Winter/Spring 1998, Vol. 17 No. 1


Sports And Recreation Survey

Sponsored by the NOPBC

Student Name:

Birth Date:

Parents Name(s):


City: State: Zip:

Home Phone:=20 E-Mail address:

Name of school:

Grade /grade level:

1. Description of vision, any other disabilities:


2. List one sport or physical activity in which you participate or have participated:


3. How long have you participated in this?

4. How did you get started?



5. Describe any special adaptations you use:




6. Have you competed in any events, won events, won trophies /awards, etc? Describe:



7. What advice would you give to other blind kids about this sport/activity?



[ ] Yes, you may give my name, address, and phone number to other parents who would like to contact me for more information.

[ ] No, you may NOT give my name, address, and phone number to others. Information from this survey may be used only for articles and other public information purposes. I understand that our names and the state we live in may be used for this purpose.

Mail to: Crystal McClain 1070 Township Road 181 Bellefontaine, Ohio 43311.