Professional Member Information Form:

Below there is an online form you may fill out and submit directly to VAAPVi. You may also click the link below to print this form. If you choose the print option, fill out the form completely and mail it to:

VAAPVI  PO Box 1523, Chesterfield  VA, 23832

Click here to print form     (you will need adobe reader to open)

 

First name          Last name       

Address            City  State  Zip 

Phone# Ex.555 555 5555                                    Email address 

I am a Professional working with children who are blind or visually impaired:          Yes                 No
Employer:  
I would like to be a part of VAAPVI’s statewide listserv for parents and professionals raising/working with children who have visual impairments? Yes        No

Check what kind of professional:

O&M                     TVI                        OT                     PT                      ST                     Physician  

Teacher                 Other    If other Please explain 

Do you or your office offer services to children?  Yes        No       

If yes, please specify:

 

Do you know of an upcoming event, clinic, or drive?   Yes        No    

If yes, please specify:

 

Would you be interested in participating in workshops?          Yes        No         Maybe

 

Would you consider using our website and newsletter to advertise your services? Yes        No    

 

To help us develop and plan our future programs, please share with us what you would like to see offered in the community.  Let us know what kind of information, education or skill building that could be a benefit to professionals or the families and children you are working with.

 

 

Thank you for taking the time to fill out our information form. Please click the "Join"  button below and your membership information will be submitted to VAAPVi. You will receive an email or letter containing your  membership details within 3-7 business days after joining.
 I would like to be contacted by:    

 Email      Regular mail      Phone

Thank You

Your membership will help to make a great difference

 

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VAAPVI a state affiliate of NAPVI - The National Association for Parents of Children with Visual Impairments, Inc.

NAPVI is a 501(c)3 organization.  Federal Tax ID available upon request.