Early Explorers Update Contact Information Form

Please complete the form below to update your contact information.

All fields marked with an asterisk(*) are required.

First name of person completing this form *

Last name of person completing this form *

Please select your relationship to the child *

If you answered other, please describe your relationship with the child.

E-mail *

Your Preferred Contact Phone Number(s).

Home Phone

Work Phone

Cell Phone

Child's First Name *

Child's Last Name *

Child's Date of birth *

Birth Date *

Month

Day

Year

Child's Height

Feet *

Inches *

Child's Address

Address 1 *

Address 2

City *

State *

Zip Code *

I would like to order a free white cane for my child. *

If, I am requesting a cane, it is more than six months since a previous request for a white cane.
I am submitting this form on behalf of a child who is a participant in the NFB Early Explorers Program.

I accept, that I have reviewed and agree to all of the statements above.

By checking this box I certify that I have read and agree with the terms stated above.