Fund for the New Jersey Blind, Inc.

Presents

“A Celebration of Partnership & Progress”

Resource Fair & Awards Luncheon

In Honor of

The 100th Anniversary

Of

THE NEW JERSEY COMMISSION FOR THE BLIND AND VISUALLY IMPAIRED

A Division of the State Department of Human Services

REGISTRATION FORM

Name: Organization______

Phone: E-mail: ______

Street Address: ______City/State/Zip: ______

Check One: Person with a visual impairment ___ Family Member ___ Professional ___ Other: ______

I Require: ASL ___CART ___ Assistive Listening Device ___ Braille ___ Wheelchair Access ______

Other required ADA accommodation: ______(Volunteers will be available to provide basic assistance.)

Vegetarian Lunch ______Othe dietary requirements (describe) ______

Important: Every person in attendance (including exhibitors and personal assistants) must pre-register for this event. This will be strictly enforced. Your registration is not confirmed until payment is received.

Cancellation Policy: All cancellations prior to 10/8/2010 will be fully refunded. No refunds after 10/8/2010.

Rain, Snow, Hail or Shine!
This event will happen regardless of weather.

This form must be completed and sent to the address below with a

check or money order payable to:

*FUND FOR THE NJ BLIND, INC.

NJCBVI 100th Anniversary

P.O. Box 47017

Newark, NJ 07101-47017

(FNJB Only) Date received ______Check # ______Confirmed ______

Registration Scholarship Information – Please Read Carefully

The Fund for the NJ Blind, Inc. and the other supporters of “A Celebration of Partnership & Progress” are pleased to offer a limited number scholarships in the amount of $40 to subsidize the expense of registering for this event.

PLEASE NOTE: Scholarship recipients will be responsible for paying $10 (the balance of the registration fee) to attend both the resource fair and awards luncheon.

Who may apply for a scholarship?

Age 18+ New Jersey residents who are visually impaired and who would otherwise be unable to attend this event.

What is the deadline for application?

The deadline for applying for a scholarship is October 1st, 2010. However, since there are a limited number available, we encourage you to apply early.

How will I find out if I received a scholarship?

You should receive an e-mail or phone call indicating the status of your application by Friday, October 8th, 2010. If you are awarded a scholarship you will receive instructions for paying the $10 balance of the registration fee.

Application: I wish to be considered for a registration scholarship, with the understanding that I will be responsible for paying the balance of the registration fee in the amount of $10.

(Briefly describe your reason for applying for the scholarship)

______

______

My signature hereon certifies that I am an adult who has a visual impairment that meets the eligibility requirements of the NJ Commission for the Blind and Visually Impaired.

______

Signature Date