Silver BELLS Registration

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

We just need to collect a few details to better help us learn a little bit about you. After you register, we'll schedule an informal intake interview to get to know you better.

If you run into any issues, please contact the program coordinator, Sandy Halverson by phone at: (703) 400-6890, or by email at: silverbells@nfbv.org.

Items marked with a * are required fields.

Registration Form

Full name

Street Address

Unit or apartment number: (optional)

City

State

Zip Code

Preferred Phone number

Is this your work, home, or cell number?

Email address

Preferred method of contact

Preferred language

Date of birth: (MM/DD/YYYY)

Name something you don’t know how to do as a blind person that you would like to know by the end of the program.

Are you familiar with the Zoom platform?

If using a phone to dial into Zoom, please provide the number from which you'll be calling

Tell us about your blindness

A family member will be attending with me

If yes, provide the family member’s name

What is their relationship to you?

This helps us make hotel room assignments.

Do you have a disability other than blindness? Please describe

For white cane measurement purposes, what is your height?

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

If selected for this program, will you need transportation?

Do you have a Windows computer at home?

Are you an Android or iPhone user?

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Silver BELLS Registration

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