REGISTRATION FORM NAPVI Family Attendant

User Manual: NAPVI-Family-attendant-registration-form

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2013 International Family Conference
July 19-21
Boston Marriott Newton
2345 Commonwealth Avenue
Newton, MA 02466

REGISTRATION FORM
Families and Professionals
(Please Print)
Name of Person Completing Form:
Address:
Street Address

City

State or Province

Country:

E-Mail:

Daytime Phone:

Evening Phone:

Organization/Affiliation:

Postal Code or Zip

(For professionals only)

CONFERENCE FEES:
Conference will be from Friday to Sunday. Your registration fee includes 4 meals, opening reception, children’s
programs, and childcare. Refunds are not available.

Age Groups

Price

Adult (19+)

$ 110.00

Child (4-18)

$ 35.00

Age 3 & Under

Free

PAYMENT METHOD:
•
•

Complete Online Registration at http://www.guildhealth.org/family and pay by credit card (VISA,
MasterCard, American Express)
Mail the registration form with Check, Purchase Order or Credit Card Payment (see p. 2 of this form)

SEND REGISTRATION FORM AND PAYMENT :
NAPVI
Jewish Guild Healthcare
15 West 65th Street
New York, NY 10023

CONFERENCE REGISTRATION:
NAPVI members will receive a 10% discount on the total registration cost for the 2013 Family
Conference. Note: NAPVI Membership is $40.00 for an individual (professional, grandparent or other extended
family member), or for a family of a child with a visual impairment (parents/guardians and their children).

#

Adults (19+)

@

$

/ Each

=

$

#

Children (4-18)

@

$

/ Each

=

$

#

Children 3 & Under (Free)
Subtotal:

*NAPVI Member Discount
#

(10% off on Subtotal Cost)

New or renewing NAPVI memberships @ $40.00/Each

$

=

$

=

$

Grand Total:

$

*Current members, please include your NAPVI 10 digit membership number:

My check or Purchase Order, payable to NAPVI, is enclosed.
Please charge $

to my

VISA

Account Number:

MasterCard

Expiration Date:

AmEx

/

Name on card:
Billing Address:
Street Address

State or Province

Postal Code or Zip

Country:

HOTEL RESERVATION:
Note: The special hotel room rate of $129 per night will be available until June 24, 2013 or until the group
block is sold out, whichever comes first. Please make your hotel reservations as soon as possible. Book online at
www.marriott.com/bosnt and enter NPVNPVA in the group code box

or
Call Marriott Hotels at 1-800-228-9290 and say you are with:
National Association for Parents of Children with Visual Impairments (NAPVI)

ADULT REGISTRATION:
Names will be used on pre-printed name tags. Please list all adults (Ages 19+) attending and
check-off selection where appropriate (PLEASE PRINT):
Name(s) of Adults

Select One
 Parent

Spanish
Interpreter
 Yes

 Grandparent  No
 Relative
 Professional
 Parent

 Yes

 Relative
 Professional
 Yes

 Relative
 Professional
 Yes

 Relative
 Professional
 Yes

 Relative
 Professional

 Professional

 No

 Braille

 None

 CD for Electronic  Gluten Free
Documents
 Vegetarian
 Regular Print  Other (List)

 Yes
 No

 Braille

 None

 CD for Electronic  Gluten Free
Documents
 Vegetarian
 Regular Print  Other (List)

 Yes
 No

 Braille

 None

 CD for Electronic  Gluten Free
Documents
 Vegetarian
 Regular Print  Other (List)

 Yes
 No

 Braille

 None

 CD for Electronic  Gluten Free
Documents
 Vegetarian
 Regular Print  Other (List)

 Yes
 No

 Large Print
 Yes

 Grandparent  No
 Relative

 Yes

 Large Print

 Grandparent  No

 Parent

 CD for Electronic  Gluten Free
Documents
 Vegetarian
 Regular Print  Other (List)

(Saturday Night)

 Large Print

 Grandparent  No

 Parent

 None

Family Event at
hotel

 Large Print

 Grandparent  No

 Parent

 Braille

Dietary
Needs

 Large Print

 Grandparent  No

 Parent

Reading
Format

 Braille

 None

 CD for Electronic  Gluten Free
Documents
 Vegetarian
 Regular Print  Other (List)
 Large Print

 Yes
 No

CHILDREN REGISTRATION:
Names will be used on pre-printed name tags. Please list all children (ages 18 and under)
attending and check-off selection where appropriate (PLEASE PRINT):
Childcare
Name(s) of Children Age Needed

Children’s
Program
Saturday and
Sunday AM

Child’s
Shirt Size

Reading
Format

 Yes

 Yes

 X-Large  Braille

 No

 No
For children
ages

 Large

Dietary
Needs
 None

Family event
at hotel
(Saturday
Night)

 Yes

 CD for Electronic  Gluten Free  No
Documents
 Medium
 Vegetarian
 Regular Print  Other (List)
 Small
 Large Print

 Yes

 Yes

 X-Large  Braille

 No

 No

 Large

 None

 Yes

 CD for Electronic  Gluten Free  No
Documents
 Medium
 Vegetarian
 Regular Print  Other (List)
 Small
 Large Print

 Yes

 Yes

 X-Large  Braille

 No

 No

 Large

 None

 Yes

 CD for Electronic  Gluten Free  No
Documents
 Medium
 Vegetarian
 Regular Print  Other (List)
 Small
 Large Print

 Yes

 Yes

 X-Large  Braille

 No

 No

 Large

 None

 Yes

 CD for Electronic  Gluten Free  No
Documents
 Medium
 Vegetarian
 Regular Print  Other (List)
 Small
 Large Print

 Yes

 Yes

 X-Large  Braille

 No

 No

 Large

 None

 Yes

 CD for Electronic  Gluten Free  No
Documents
 Medium
 Vegetarian

Regular
Print
 Small
 Other (List)
 Large Print

MEALS:
Please indicate the number of people attending who will need meals (Children 0-3 eat free):
Events
Friday Opening Reception

Number of Adults

Number of Children

Saturday Breakfast
Saturday Lunch
Saturday Night Family Dinner
and Activities at Hotel
Sunday Breakfast

EYE NETWORKING SESSION:
Parents are encouraged to attend the Eye Condition and/or Disability Network Session on
Saturday at 10:15 AM. Please check the group you would like to attend.










Achromatopsia
Albinism
Aniridia
Anophthalmia/Microphthalmia
Cataracts & Glaucoma
CHARGE
Colaboma
Cortical Visual Impairment
Corneal Disease












Deafblind
Leber’s Congenital Amaurosis
Multiple Disabilities
Optic Nerve Atrophy/Hypoplasia
Retinal Conditions
Retinitis Pigmentosa
Retinoblastoma
Retinopathy of Prematurity
Stargardt's Disease
Other Visual Condition

If there is further registration information you feel we need to have, please explain:
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