Future Reflections                                                                                       Convention, 2002

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Completed form and fees must be received on or before June 15, 2003

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         $ ________

We understand that NFB Camp is provided as a service by the NFB to make our convention more enjoyable for both parents and children. We understand the rules we were given and agree to abide by them. We will pick up children immediately following sessions. We understand that, if our child(ren) does not follow the rules or if for any reason staff is unable to care for our child(ren), further access to childcare will be denied.

Parents Signature __________________________________ Date _______________

Make checks payable to NFB Cam
Return form to National Federation of the Blind of Oregon
5005 Main Street, Springfield, Oregon 97478, (541) 726-6924

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