KENTUCKY PARENTS OF BLIND CHILDIZEN

MEMBERSHIP FORM

Name(s):_______________________________________________________

Address:_______________________________________________________

City___________________________ State___________ Zip______________

Telephone Number: (___)___-____

Name of blind child:________________________________ DOB_________

NIame(s) of other children: 1._____________________________________

2._____________________________________

3._____________________________________

( ) Parent(s) ( ) Teacher of visually impaired

( ) Other_______________________________________________________

KPBC dues are $6 per year

Make checks payable to KPBC

Mail form and dues to: Maria Jones, President

3827 Chevy Chase Rd.

Louisville, KY 40218