GETTING TO KNOW YOU PEER SURVEY
A Peer Network for All Impacted by Vision Loss Fields with * are strongly requested
What is your current age range
Phone #1 please use only numbers no dashes or parentheses
Phone #2 please use only numbers no dashes or parentheses
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
Are You a Person with Vision Loss
If yes, how long have you experienced vision loss?
Less than 2 years
2 to 5 years
5 to 10 years
More than 10 years
If you are not a person with Vision loss, how are you impacted by vision loss?
If you wish to tell us about any disabilities other than vision loss or blindness, please do so here:
Select your annual membership type
Individual Adult At Large $10.00
Non Profit Agency $20.00
Individual Junior (under 18) $5.00
Corporate - For Profit $60.00
Chapter/Affiliate Member $TBD
Which of the following PCB offerings are of interest to you? Check all that apply
Local Chapters (additional fee may be required)
AccessiDocs Document Conversion Service
Vision Loss Resources
Public Awareness & Peer Outreach Literature
American Council of the Blind
iDevices for Independence
PCB Telephone Information Line
Topical Discussion Calls
Public Policy/Advocacy Projects
Leadership and Volunteer Opportunities
Having/Being a Vision Loss Mentor
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.)
which of the following topical areas are of interest to you? (Check all that apply)
Adjusting to vision loss
Health & Fitness
Transitioning to Adulthood
If you answered Other above, please describe what area or areas you are interested in:
If you are seeking vision loss resources, please tell us more about your needs so we can best offer assistance.
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
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.
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