Sight Care Registration Form 5 25

User Manual: SightCare Registration Form 5-25

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Incorporating Low Vision Rehabilitation
into Occupational Therapy
Registration Form September 23, 2011

First Name:

Last Name:

Describe your employer and/or the population are you serving:

What low vision techniques are you currently using:

Mailing Address (check one)

Home

Business

Billing Address (if different than mailing address)

Address line 1:

Address line 1:

Address line 2:

Address line 2:

City:

City:

State:

ZIP:

State:

ZIP:

Check here if same as billing address.

Email:

Daytime Phone:

Individual Registration: $125

AOTA Member: $95

NUMBER OF REGISTRATIONS:

TOTAL DUE: $

Please complete and attach a registration form for each person attending, even if making one payment

1. TO PAY BY CREDIT CARD:
Visa

Mastercard

2. TO PAY BY PURCHASE ORDER, BILL TO:
American Express

Org:

Credit Card No:
Expiration Date:

Name:

/

Address:

Print Name:

City:

Signature:

Daytime Phone:

Daytime Phone:

Purchase Order Number:

State:

Mail completed form to address below, fax to 212-595-4907, or scan and email to sightcare@jgb.org

3. TO PAY BY MAIL (Check or Money Order):
Make check or money order payable to The Jewish Guild for the Blind
Mail with completed form to:
The Jewish Guild for the Blind / SightCare
15 West 65th Street
New York, NY 10023
Attention: Eileen Morrissey
Questions:
Call 800-539-4845 or email sightcare@jgb.org
SightCare is a program of The Jewish Guild for the Blind

800-539-4845

www.jgb.org

ZIP:
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