2004
NFB Summer Science Experience
Interest Form
Please complete the following form and submit it to Mrs. Barbara Cheadle, President, National Organization of Parents of Blind Children, 1800 Johnson Street, Baltimore, Maryland 21230. You may also submit this information by email to <bcheadle@nfb.org>, or by fax, attention Mrs. Cheadle, at: (410) 685-5653. Please note: this is a form to register interest, not an application. A confirmation letter with additional information and/or an application packet will be sent to you upon receipt of the interest form. Please print legibly.
I/we are interested in the [ ] Session I: Circle of Life [ ] Session II: Rocket On!
Student’s name: __________________________________________________________
Birth date: ___________________________ Grade: ____________________________
Parent/guardian name(s): ___________________________________________________
Home address: ___________________________________________________________
City, State, Zip: __________________________________________________________
Please indicate the best way(s) and time(s) to contact you:
Home phone: ( ) ________________________________________________________
Work phone: ( ) ________________________________________________________
Cell phone: ( ) _________________________________________________________
Email, home: ____________________________________________________________
Email, work: ____________________________________________________________
If you are someone other than the parent or the student listed above (such as a teacher), please print your name, your relationship to the student, and the way we may contact you: ________________________________________________________________________
For more information regarding the 2004 NFB Summer Science Experience, contact Mark A. Riccobono, Coordinator of Educational Programs, National Federation of the Blind, Research and Training Institute, (410) 659-9314, extension 368, <mriccobono@nfb.org>.
For questions regarding the application process contact Barbara Cheadle, President, National Organization of Parents of Blind Children, (410) 659-9314, extension 360, <bcheadle@nfb.org>.