General Information Complete the form below with details as it relates to your NFB BELL Academy in-person program(s). This information will be posted on your affiliate NFB BELL Academy webpage for interested participants to learn more information about your NFB BELL Academy. You may save this form and complete at a later date, if needed. If you do not receive a confirmation email, we may not have received your submission. If you need revisions, contact us at [email protected] or call 410-659-9314, extension 2418. Affiliate Affiliate - Optional Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of ColumbiaAmerican SamoaGuamNorthern Mariana IslandsPuerto RicoVirgin IslandsMinor Outlying IslandsVirtualTBDOther… Enter other… - Optional How many program locations are you entering? You can select up to five. * - Optional - Select -12345 State Coordinator Contact Information First Name - Optional Last Name - Optional Primary Phone - Optional Email - Optional Do additional people need to access the dashboard? - Optional - Select -YesNo Number of additional people - Optional - Select -1234 Second Statewide Coordinator Second State Coordinator First Name - Optional Second State Coordinator Last Name - Optional Second State Coordinator Email - Optional Second State Coordinator Phone - Optional Third Statewide Coordinator Third State Coordinator First Name - Optional Third State Coordinator Last Name - Optional Third State Coordinator Email - Optional Fourth Statewide Coordinator Fourth State Coordinator First Name - Optional Fourth State Coordinator Last Name - Optional Fourth State Coordinator Email - Optional Fifth Statewide Coordinator Fifth State Coordinator First Name - Optional Fifth State Coordinator Last Name - Optional Fifth State Coordinator Email - Optional Program Details For Location One Program Coordinator First Name - Optional Program Coordinator Last Name - Optional Program Coordinator Primary Phone Number - Optional Program Coordinator Email - Optional Program Information Program Title - Optional Please select your program structure - Optional - None -2-week day program1 week- residential programOther (Affiliate Braille Camp) Program Location Address - Optional Program Location City - Optional Program Location Zip - Optional Program Start Date - Optional Program End Date - Optional Program Start Hours - Optional Program End Hours - Optional Lunch Information - Optional Registration Fee Information - Optional Transportation Information - Optional Please list any additional information to be included on your affiliate’s NFB BELL Academy web page - Optional If families want more information who should they contact? - Optional Contact Person Full Name - Optional Contact Person Phone Number - Optional Contact Person Email - Optional When do you want to close registration? - Optional National will provide your affiliate with an accessible PDF flyer for marketing. Do you want an additional copy in Spanish? - Optional - None -YesNo Program Compliance Information Does your affiliate have a current certificate of insurance on file with national? - Optional - None -YesNo Does your affiliate have an adopted Youth Program Protection Policy on file with national? - Optional - None -YesNo Program Details For Location Two Program Coordinator First Name - Optional Program Coordinator Last Name - Optional Program Coordinator Primary Phone Number - Optional Program Coordinator Email - Optional Program Information Program Two Title - Optional Please select your program structure - Optional - None -2-week day program1 week- residential programOther (Affiliate Braille Camp) Program Location Address - Optional Program Location City - Optional Program Location Zip - Optional Program Start Date - Optional Program End Date - Optional Program Start Hours - Optional Program End Hours - Optional Lunch Information - Optional Registration Fee Information - Optional Transportation Information - Optional Please list any additional information to be included on your affiliate’s NFB BELL Academy web page - Optional If families want more information who should they contact? Please provide a name, phone number and email address. - Optional Contact Person Full Name - Optional Contact Person Phone Number - Optional Contact Person Email - Optional When do you want to close registration? - Optional National will provide your affiliate with an accessible PDF flyer for marketing. Do you want an additional copy in Spanish? - Optional - None -YesNo Program Compliance Information Does your affiliate have a current certificate of insurance on file with national? - Optional - None -YesNo Does your affiliate have an adopted Youth Program Protection Policy on file with national? - Optional - None -YesNo Program Details For Location Three Program Coordinator First Name - Optional Program Coordinator Last Name - Optional Program Coordinator State - Optional - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of ColumbiaAmerican SamoaGuamNorthern Mariana IslandsPuerto RicoVirgin IslandsMinor Outlying Islands Program Coordinator Primary Phone Number - Optional Program Coordinator Email - Optional Program Information Program Three Title - Optional Please select your program structure - Optional - None -2-week day program1 week- residential programOther (Affiliate Braille Camp) Program Location Address - Optional Program Location City - Optional Program Location Zip - Optional Program Start Date - Optional Program End Date - Optional Program Start Hours - Optional Program End Hours - Optional Lunch Information - Optional Registration Fee Information - Optional Transportation Information - Optional Please list any additional information to be included on your affiliate’s NFB BELL Academy web page - Optional If families want more information who should they contact? Please provide a name, phone number and email address. - Optional Contact Person Full Name - Optional Contact Person Phone Number - Optional Contact Person Email - Optional When do you want to close registration? - Optional National will provide your affiliate with an accessible PDF flyer for marketing. Do you want an additional copy in Spanish? - Optional - None -YesNo Program Compliance Information Does your affiliate have a current certificate of insurance on file with national? - Optional - None -YesNo Does your affiliate have an adopted Youth Program Protection Policy on file with national? - Optional - None -YesNo Program Details For Location Four Program Coordinator First Name - Optional Program Coordinator Last Name - Optional Program Coordinator Primary Phone Number - Optional Program Coordinator Email - Optional Program Information Program Four Title - Optional Please select your program structure - Optional - None -2-week day program1 week- residential programOther (Affiliate Braille Camp) Program Location Address - Optional Program Location City - Optional Program Location Zip - Optional Program Start Date - Optional Program End Date - Optional Program Start Hours - Optional Program End Hours - Optional Lunch Information - Optional Registration Fee Information - Optional Transportation Information - Optional Please list any additional information to be included on your affiliate’s NFB BELL Academy web page - Optional If families want more information who should they contact? Please provide a name, phone number and email address. - Optional Contact Person Full Name - Optional Contact Person Phone Number - Optional Contact Person Email - Optional When do you want to close registration? - Optional National will provide your affiliate with an accessible PDF flyer for marketing. Do you want an additional copy in Spanish? - Optional - None -YesNo Program Compliance Information Does your affiliate have a current certificate of insurance on file with national? - Optional - None -YesNo Does your affiliate have an adopted Youth Program Protection Policy on file with national? - Optional - None -YesNo Program Details For Location Five Program Coordinator First Name - Optional Program Coordinator Last Name - Optional Program Coordinator Primary Phone Number - Optional Program Coordinator Email - Optional Program Information Program Five Title - Optional Please select your program structure - Optional - None -2-week day program1 week- residential programOther (Affiliate Braille Camp) Program Location Address - Optional Program Location City - Optional Program Location Zip - Optional Program Start Date - Optional Program End Date - Optional Program Start Hours - Optional Program End Hours - Optional Lunch Information - Optional Registration Fee Information - Optional Transportation Information - Optional Please list any additional information to be included on your affiliate’s NFB BELL Academy web page - Optional If families want more information who should they contact? Please provide a name, phone number and email address. - Optional Contact Person Full Name - Optional Contact Person Phone Number - Optional Contact Person Email - Optional When do you want to close registration? - Optional National will provide your affiliate with an accessible PDF flyer for marketing. Do you want an additional copy in Spanish? - Optional - None -YesNo Program Compliance Information Does your affiliate have a current certificate of insurance on file with national? - Optional - None -YesNo Does your affiliate have an adopted Youth Program Protection Policy on file with national? - Optional - None -YesNo Number of Virtual Programs - Optional - Select -123456 First Virtual Version Event Name 1 - Optional Civi Id for Event 1 - Optional Second Virtual Version Event Name 2 - Optional Civi Id for Event 2 - Optional Second Virtual Version Event Name 3 - Optional Civi Id for Event 3 - Optional Fourth Virtual Version Event Name 4 - Optional Civi Id for Event 4 - Optional Fifth Virtual Version Event Name 5 - Optional Civi Id for Event 5 - Optional Fifth Virtual Version Event Name 6 - Optional Civi Id for Event 6 - Optional Submit Leave this field blank - Optional
