Your Contact Information
- Select - Outside United States Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming
Please select your relationship to the child.
- Select - Mother Father Grandmother Grandfather Legal Guardian Teacher Other
If you answered Other, please describe your relationship with the child.
Participating Child's Information
Child's Birth Year
- Select - 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Child's Birth Date
- Select - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Child's Birth Month
- Select - January February March April May June July August September October November December
Is this the child’s first time participating in the Braille Reading Pals program?
- Select - Yes No
- None - Caucasian African American Hispanic Asian Other
If other, please specify:
Does the child have any additional impairment that impacts his or her learning? If so, check all that apply:
Other (please specify):
What is the approximate average annual household income for the child’s primary residence?
Please Select Average Annual Household Income $0-$20,000 $20,000-$40,000 $40,000-$60,000 $60,000-$80,000 $80,000-$100,000 More than $100,000
Who reads to the child most of the time?
Please Select Primary Reader Mother Father Grandmother Grandfather Sibling Guardian Teacher
What is the highest level of education completed by this person?
Please Select Highest Level of Education No high school diploma High school College classes, no degree Associates Degree Bechelor's Degree Master's Degree or higher
How often does this person read to the child?
Select how often this person reads to the child Several times a day Once a day Several times a week Once a week Less than once a week
How many minutes does the child typically stay engaged when you or someone else is reading to him or her?
Which types of books are read to the child?
Select Type of Books All print Mostly print A combination of print and Braille Mostly Braille All Braille
If Braille books are read to the child, is he or she encouraged to explore the Braille tactually during the reading?
- None - Yes No
Are objects in the child’s home labeled in large print or Braille?
- None - Yes, in print Yes, in Braille Yes, in both print and Braille No
Have you found this to be helpful, and how has it been helpful?
How did you hear about this program?
- None - Future Reflections Child's school National Parents of Blind Children (NOPBC) contact NFB state or local affiliate NFB listserv Received a postcard about the program Other
Do you receive Future Reflections?
- None - Yes No
If no, would you like to subscribe to Future Reflections? Future Reflections is available free of charge to subscriber addresses in the United States in regular print, USB drive, via e-mail, or online on the NFB site. Canadian subscriptions $35/yr
- None - Yes, please send it to me in regular print Yes, please send it to me on a USB drive Yes, please send it to me via e-mail No thank you, I already subscribe No thank you, I'm not interested
I wish to register for the 2011 Braille Reading Pals Club. I understand this is an early Braille literacy program for blind and low vision pre-readers (babies, toddlers, preschoolers, and young children who are not yet independent readers). This program is for children ages seven or younger, and the child/children that I am registering are currently within this age range. Participants in this program must be under the age of eight by the beginning of the program year, which is January 1, 2011. This program is only open to participants in the United States and Canada.