Sports and Recreation Survey

Sports and Recreation Survey

Future Reflections Winter/Spring 1998, Vol. 17 No. 1
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Sports And Recreation

Survey
Sponsored by the NOPBC
Student Name:
Birth Date:
Parents Name(s):
Address:
City: State: Zip:
Home Phone:=20 E-Mail address:
Name of school:
Grade /grade level:
1. Description of vision, any other disabilities:

2. List one sport or physical activity in which

you participate or have participated:

3. How long have you participated in this?
4. How did you get started?

5. Describe any special adaptations you use:

6. Have you competed in any events, won events,

won trophies /awards, etc? Describe:

7. What advice would you give to other blind kids

about this sport/activity?

[ ] Yes, you may give my name, address, and phone

number to other parents who would like to contact me for more

information.
[ ] No, you may NOT give my name, address, and

phone number to others. Information from this survey may be used

only for articles and other public information purposes. I understand that our names and

the state we live in may be used for this purpose.
Mail to: Crystal McClain 1070 Township Road 181

Bellefontaine, Ohio 43311.
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