Family 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)

 

Note: This transmission is intended only for the use of the person or office to whom it is addressed and may contain confidential information that is privileged, confidential or protected by law.

Your name                    Spouses name          

Address              City  State  Zip 

                                                                                    Email address 

Phone# Ex.555 555 5555

I am a Parent of a child with a visual impairment:

 Yes
No

I am a Professional

 Yes    
No    
I would like to be a part of VAAPVI’s online data base of parents, to connect with other parents. (The database will only share your first name only, email address, and child’s diagnosis (not child’s name) and only other parent members will have access via log in that is password secured)    Yes
No
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  
     
Child's name   Child's DOB                                                   

Grade Level

School attended               Eye condition

Child’s functional vision:                 Totally blind                  Light perception only                 Low vision  

Please elaborate on vision:    

Age that vision loss occurred:   

Other diagnosis:  

 Reading/writing medium:    Braille         Large Print
Circle services currently received IN the school system and frequency:
OT  PT  ST O&M  TVI

Ex. Two hours Daily

 What kind of technology/assistance used in the school related to disability:

 

 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.