I (we) would like to support the efforts of MPVI by becoming a member (enclosed is my tax deductible $10)
I (we) would like to support MPVI with an additional tax deductible donation of:
No Donation at this time:
I (we) would like to receive mailings but not be a paying member at this time
Name:
Street Address:
City:
State:
Zip Code:
Phone:
E-mail:
Please send mailings by e-mail only (saves trees and MPVI $):
Yes
No
My child’s name is:
His/Her birth date is:
My child’s eye condition is:
I am a:
I would like to be put in contact with parents whose child has a similar eye condition.
Yes
No
My child has other disabilities as well as visual impairment and I’d like to be put in contact with parents of children with similar multiple disabilities. The disability(ies) of most concern to me are:
Permission:
I give permission to release information about me to other parents and organizations working with vision impairments
Please do not release my name to anyone
Thanks for responding!
Please make checks payable to MPVI and mail to: Jim Botting, MPVI Membership Chair 4175 Westbrook Rd. Ionia MI 48846
