Future Reflections                                                                                          Spring, 2002

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NFB CAMP PREREGISTRATION FORM

Completed form and fees must be received on or before June 15, 2002.

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 $ _________________

Make checks payable to and return forms to:

National Federation of the Blind of Oregon

5005 Main Street, Springfield, Oregon 97478

(541) 726-6924

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