REGISTRATION FORM2015 NAPVI National Family Conference 2015

User Manual: NAPVI-National-Family-Conference-2015-Registration

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

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

Early Bird
Registration

After May 31

Adult (19+)

$ 85.00

$ 110.00

Child (4-18)

$ 25.00

$ 35.00

Age 3 & Under

Free

PAYMENT METHOD:
•
•

Complete Online Registration at http://www.lighthouseguild.org/napvifamily2015 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
Lighthouse Guild
15 West 65th Street,
New York, NY 10023

CONFERENCE REGISTRATION:
NAPVI members will receive a 10% discount on the total registration cost for the 2015 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+)

$110.00 / Each

Children (4-18)

$35.55 / Each

Children 3 & Under (Free)
Subtotal:

*NAPVI Member Discount
#

(10% off 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

MasterCard

AmEx

Account Number: ________________________________________________ Expiration Date: _______/______
Name on card:
Billing Address:
Street Address

State or Province

Postal Code or Zip

Country:

HOTEL RESERVATION:
Note: The special hotel room rate of $169 per night will be available until June 9, 2015 or until the group block
is sold out, whichever comes first. Please make your hotel reservations as soon as possible. Book online at
http://www.lighthouseguild.org/napvifamily2015 for a direct link to the hotel 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
(Ages 19+)

Select One

Spanish
Interpreter

Reading
Format

Dietary
Needs

Family Reception
(Friday Night)

! Parent

! Yes

! Braille

! None

! Yes

! Grandparent

! No

! CD for Braille
Documents

! Gluten Free

! No

! Regular Print
! Large Print

! Other (List)
____________

! Relative
! Professional

! Vegetarian

! Parent

! Yes

! Braille

! None

! Yes

! Grandparent

! No

! CD for Braille
Documents

! Gluten Free

! No

! Regular Print
! Large Print

! Other (List)
____________

! Relative
! Professional

! Vegetarian

! Parent

! Yes

! Braille

! None

! Yes

! Grandparent

! No

! CD for Braille
Documents

! Gluten Free

! No

! Regular Print
! Large Print

! Other (List)
____________

! Relative
! Professional

! Vegetarian

! Parent

! Yes

! Braille

! None

! Yes

! Grandparent

! No

! CD for Braille
Documents

! Gluten Free

! No

! Regular Print
! Large Print

! Other (List)
____________

! Relative
! Professional

! Vegetarian

! Parent

! Yes

! Braille

! None

! Yes

! Grandparent

! No

! CD for Braille
Documents

! Gluten Free

! No

! Regular Print
! Large Print

! Other (List)
____________

! Relative
! Professional

! Vegetarian

! Parent

! Yes

! Braille

! None

! Yes

! Grandparent

! No

! CD for Braille
Documents

! Gluten Free

! No

! Regular Print

! Other (List)
____________

! Relative
! Professional

! Large Print

! Vegetarian

CHILDREN REGISTRATION:
Names will be used on pre-printed name tags. Please list all children (ages 0 to 18) attending
and check-off selection where appropriate (PLEASE PRINT):
Name(s) of Children
(Ages 0-18)

Childcare
Age Needed

Children’s
Program
Saturday and
Sunday AM

Child’s
Shirt Size

Reading
Format

Dietary
Needs

Family
Reception
(Friday Night)

! Yes

! X-Large

! Braille

! None

! Yes

! No

! Large

! CD for Braille
Documents

! Gluten Free

! No

! Regular Print
! Large Print

! Other (List)
__________
__________

! Medium
! Small

! Vegetarian

! Yes

! X-Large

! Braille

! None

! Yes

! No

! Large

! Gluten Free

! No

! Medium

! CD for Braille
Documents

! Small

! Regular Print
! Large Print

! Other (List)
__________
__________

! Vegetarian

! Yes

! X-Large

! Braille

! None

! Yes

! No

! Large

! CD for Braille
Documents

! Gluten Free

! No

! Regular Print

! Other (List)
__________

! Medium
! Small

! Large Print

! Vegetarian

__________
! Yes

! Yes

! X-Large

! Braille

! None

! Yes

! No

! Large

! Gluten Free

! No

! Medium

! CD for Braille
Documents

! Small

! Regular Print
! Large Print

! Other (List)
__________
__________

! Vegetarian

! Yes

! X-Large

! Braille

! None

! Yes

! No

! Large

! Gluten Free

! No

! Medium

! CD for Braille
Documents

! Small

! Regular Print

! Other (List)
__________
__________

! Large Print

! Vegetarian

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

Events
Friday Night Opening Reception

Number of Adults

Number of Children

Saturday Breakfast

Saturday Lunch

Saturday Night Family Activities

Sunday Breakfast

NETWORKING SESSION:
Parents are encouraged to attend the Networking Session and/or Eye Condition Session on
Saturday. 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

EYE CONDITION SESSION:
Parents are encouraged to attend the Networking Session and/or Eye Condition Session on
Saturday. Please check the group you would like to attend.

Group A: Stem Cell Research and Inherited Retinal Diseases
Group B: Albinism and Ocular Genetics
Group C: Ocular Trauma and Retinal Conditions
Group D: Congenital Disorders
Group E: Juvenile Cataracts and Ocular Motility Disorders
Group F: Corneal Disease

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

CHILD BACKGROUND INFORMATION
Must Be Completed for Each Child (0-18 Years of Age)

Dear Parents:
Please complete this form for each child attending the 2015 International Family Conference,
including the child with a visual impairment. We need this information to plan childcare and
our educational programs.
You will find additional copies of this form and complete information about the conference
at http://www.lighthouseguild.org/napvifamily2015

To provide the best possible experience for your child, make sure everything
is labeled with the child’s name (bottles, toys, diaper bags, etc.)
Administering medications will be the responsibility of the parent.

Please complete the Child Background Information Form, along with the Activity
Permission for Children and Media Release forms and return with your payment and
Registration to:
NAPVI National office at
Lighthouse Guild
15 West 65th Street
New York, New York 10023
Best regards,
Conference Planning Committee
For more information: NAPVI@lighthouseguild.org

CHILD BACKGROUND INFORMATION

Must Be Completed for Each Child (0-18 Years of Age)
(Please Print)
CHILD INFORMATION:
Name of Child:

! Male

Age:

! Female

Person filling out the form and relationship to the child:
Check all that apply:
! Child is blind or visually impaired
! Child is deafblind
! Child is blind or visually impaired with additional disabilities
! Child is a sibling of a child who is blind or visually impaired and/or has additional disabilities
! Other (please explain):
Name of Parents/Guardians:
Home Phone: (

)

Cell Phone: (
)
Or best way to contact you during the conference

HEALTH/MEDICAL:
"

If the child has allergies to food, medicine, insects, or other areas please list:

Current medical conditions:

Does the child have:

Does the child have a medically prescribed diet or have dietary restrictions?

History of Seizures
! Yes ! No

Diabetes
! Yes ! No

Asthma
! Yes ! No
! Yes ! No

If yes, please explain:
"

Does the child have other activity limitations? ! Yes ! No
If yes, please explain:

Is there other health information to share with us?

Student’s Visual Diagnosis:

Child Wears: ! Glasses

! Contact Lenses ! Hearing Aids

! Prosthesis ! Other _________ ! N/A

Child Background Information Form, Page 2 of 2

COMMUNICATION:
"

Does the child need a sign language interpreter: ! Yes ! No

The child uses: ! Large Print

Language child speaks:

! Regular Print

! Braille

! N/A

Language spoken in the home:

TRAVEL AND MOBILITY (Check all that apply):
! Walks independently

! Walks unaided, but with difficulty

! Uses cane

! Requires physical support

! Climbs stairs independently

! Cannot climb stairs, even with assistance

! Uses wheelchair

! Uses orthopedic device (e.g., braces, walker, crutches)

! Aided ! Unaided

SELF-CARE SKILLS:
"

Eating (Select One):
! Needs no assistance
! Needs assistance, such as:

Toileting (Select One):
! Needs no assistance/toilets independently
! Schedule trained
! Needs some assistance, such as:

BEHAVIOR:
Please describe in detail any behavior issues, even if they do not happen all the time at home (i.e., what might
these behaviors look like? What might cause them? What seems to help in those situations?)

This health history is correct so far as I know, and the child listed above has permission to engage in all childcare
activities except as noted.
1. Any situation requiring medical attention will be called to my attention immediately.
2. In the event I cannot be reached during an emergency with my child, I give personnel of the International
Family Conference permission to seek emergency medical treatment.
3. I will be responsible for giving any medications my child needs.
4. I will be responsible for any special diet my child needs.
Signature of Parent/Guardian
Print Name of Parent/Guardian

Date

ACTIVITY PERMISSION
Must Be Completed for Children
(Age 18 and under)
(Please Print)

To be completed by parents or guardians
I, _____________________________________________ (Parent Name) give permission
for my child/children (Print Names)

to participate in any/all off-site activities planned for the children registered for the
childcare program during the International Family Conference on July 10-12, 2015.

Signature (Parent/Guardian):

Printed Name (Parent/Guardian):

Date:

RELEASE AGREEMENT
1. I understand the photograph(s) or video or audio recording(s) taken of me by agents, employees or
representatives of Lighthouse Guild, which includes each of its subsidiaries shall be used in connection
with Lighthouse Guild's dissemination of information by its public service and education programs to
the general public.
2. I hereby irrevocably authorize Lighthouse Guild to photograph or videotape me and to use, copy,
reproduce, edit, exhibit, publish or distribute any and all such images and audio of me or wherein I
appear, including composite or artistic forms and media, including videos and television, online
programs and Internet sites, for purposes of publicizing the Guild’s programs or for any other lawful
purpose. I understand this may include certain educational materials that may be offered for sale.
3. I authorize my name to be used together with the photograph

_____Yes

_____No

4. I waive any right to inspect or approve the finished product, including written copy, wherein my
likeness appears.
5. This release is worldwide and perpetual and is governed by the laws of New York State.
6. I hereby hold harmless and release and forever discharge Lighthouse Guild from all claims, demands
and causes of action which I, my heirs, representatives, executors, administrators or any other persons
acting on my behalf or on behalf of my estate have or may have by reason of this authorization.
7. I am 18 years of age or older and am competent to contract in my own name. I have read this release
before signing below and I fully understand the contents, meaning, and impact of this release.
___________________________________

_______________________________

(Signature)

(Date)

___________________________________

_______________________________

(Printed Name)

(Street Address)

______________________________________________________________________________
(City, State, Zip Code)
If this release is for a person under age 18, the consent must be signed by a parent or guardian

I hereby certify that I am the parent or guardian of __________________________, a minor, and do
hereby give my consent without reservations to all of the foregoing on behalf of this person.
_________________________________

_______________________________

(Signature)

(Date)

_________________________________
(Printed Name)
th

NAPVI,
Lighthouse
Guild,
15
West
65
Street,
New
York,
New
York,
10023

2015

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REGISTRATION FORM2015 NAPVI National Family Conference 2015

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