Future Reflections                                                                                           Convention 2004

(back) (next) (contents)

 

2004 NFB Summer Science Experience
Interest Form

Please complete the following form and submit it to Mrs. Barbara Cheadle, President, National Organization of Parents of Blind Children, 1800 Johnson Street, Baltimore, Maryland 21230. You may also submit this information by email to <bcheadle@nfb.org>, or by fax, attention Mrs. Cheadle, at: (410) 685-5653. Please note: this is a form to register interest, not an application. A confirmation letter with additional information and/or an application packet will be sent to you upon receipt of the interest form. Please print legibly.

I/we are interested in the††††††† [† ] Session I: Circle of Life†††††††† [† ] Session II: Rocket On!

Studentís name: __________________________________________________________

Birth date: ___________________________† Grade: ____________________________

Parent/guardian name(s): ___________________________________________________

Home address: ___________________________________________________________

City, State, Zip: __________________________________________________________

Please indicate the best way(s) and time(s) to contact you:

Home phone: (†††† ) ________________________________________________________

Work phone: (†††† ) ________________________________________________________

Cell phone: (†††† ) _________________________________________________________

Email, home: ____________________________________________________________

Email, work: ____________________________________________________________

If you are someone other than the parent or the student listed above (such as a teacher), please print your name, your relationship to the student, and the way we may contact you: ________________________________________________________________________

For more information regarding the 2004 NFB Summer Science Experience, contact Mark A. Riccobono, Coordinator of Educational Programs, National Federation of the Blind, Research and Training Institute, (410) 659-9314, extension 368, <mriccobono@nfb.org>.

For questions regarding the application process contact Barbara Cheadle, President, National Organization of Parents of Blind Children, (410) 659-9314, extension 360, <bcheadle@nfb.org>.

(back) (next) (contents)