Future Reflections                                                                                     Spring/Summer 2004

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NFB Camp Registration Form

Completed form and fees must be received on or before June 15, 2004

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.

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