PCB Network Membership
A Peer Network for All Impacted by Vision Loss
Name *
Your answer
Birth Date
MM
/
DD
/
YYYY
What is your current age range *
Required
Street Address *
Your answer
City/State/Zip *
Your answer
County *
Your answer
Phone #1 please use only numbers no dashes or parentheses *
Your answer
Phone #2 please use only numbers no dashes or parentheses
Your answer
Email
Your answer
Please note: All Members will be automatically added to PCB's email distribution list. Announcements of events, opportunities, and resources are sent out 2 to 3 times each month. For members without email access, PCB posts monthly updates to the PCB Information Line, available by calling 773-572-6314
Preferred Format of Material *
Required
Are You a Person with Vision Loss
If yes, how long have you experienced vision loss?
If you are not a person with Vision loss, how are you impacted by vision loss?
Select your annual membership type *
Required
Which of the following PCB offerings are of interest to you? Check all that apply *
Required
Are you interested in being listed in a data base of individuals who provide peer support to others impacted by vision loss? Please note your name, email and telephone information will be shared with individuals who contact the PCB office seeking peer guidance.
If yes, what type of experience or expertise might you be comfortable providing? (e.g. assistive technology, parenting, organizing, a specific occupation, language fluency, etc.)
Your answer
which of the following topical areas are of interest to you? (Check all that apply)
If you answered Other above, please describe what area or areas you are interested in:
Your answer
If you are seeking vision loss resources, please tell us more about your needs so we can best offer assistance.
Your answer
Please note: PCB program coordinators will contact you to provide or gather additional information based on your responses to all questions.
Address: 931 N Front St, Ste B, Harrisburg, PA 17102
Phone (717) 920-9999 or toll free (877) 617-7407
Pre-Recorded Information Line: (773) 572-6314
Website: www.pcb1.org
Facebook: PACounciloftheBlind
Twitter: @PCB_Advocate
Upon Clicking the "Submit: button your information will be sent to PCB and you will be directed to our Pay Pal page to purchase your annual membership. If you are a member of a local chapter, please close out of the Pay Pal screen and pay for your annual membership through your chapter's treasurer.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms