Silver Bells Registration

We’re excited you’ve chosen to take the first step in joining us!

If you have difficulty in completing this form, or to learn about exciting opportunities throughout this year, please contact the program coordinator, Rachel Schreiman, by phone at: 571-419-0512, or by email at: silverbells@nfbv.org.

Full name

Date of birth: (MM/DD/YYYY)

Street Address

Unit or apartment number: (optional)

City

State

Zip Code

Primary phone number

Is this a cellular or land line?

Optional secondary phone number:

Is this a cellular phone or land line?

Email address

Additional contact's full name:

Phone number:

Is this a cellular phone or land line?

Email address:

Will a family member or companion attend with you?

If yes, provide the family member or companion’s name.

What is their relationship to you?

This helps us make hotel room assignments.

Are you an Android or iPhone user?

For white cane measurement purposes, what is your height?

Please enter height in feet and inches. For example: 5'6.

Do you have a disability, injury or mobility challenge other than blindness that might impact your participation?

If yes, please describe.

Do you use a mobility device such as a walker?

Do you need an accessible room with a walk-in shower? (Subject to availability.)

Do you have any food allergies of which we should be aware?

If yes, please explain.

If selected for this program, will you need transportation assistance? (Please note this is not guaranteed and we ask that you provide your own transportation if possible.)

What is your preferred retreat?

Please note: Transportation can only be provided within your geographic region.

Which of the following best describes your current level of vision?

Do you still drive?

Are you a Veteran or Veteran Dependent?

How did you hear about us?

Please specify the individual's name who, or organization's name that, referred you, if applicable.

I understand that I will be required to sign a liability release to attend a retreat.

Is there anything else you would like us to know that will help staff make this a safe and enjoyable program for you?

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