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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