2017 Adult Summer Program Interest Form
Please complete this form, and submit it to indicate your interest in the Adult Summer Program at WCBVI. Classes will be held Sunday, August 6 through Friday, August 11, 2017 at the Janesville Campus. Questionnaires will be sent following receipt of this form.
Sheila
Your answer
Your Last Name
Your answer
Your Address, line 1
Your answer
Your Address line 2
Your answer
Your City
Your answer
Your State
Your answer
Your Zip
Your answer
Your Email Address
Your answer
Your Prefered Telephone Number
Your answer
Your Other Telephone Number
Your answer
How long have you been blind or visually impaired?
Your answer
What is the cause of your visual impairment?
Your answer
What is your visual accuity?
Your answer
Will you be able to attend the entire one-week program?
Have you attended the WCBVI Adult Program in the past?
Submit
Never submit passwords through Google Forms.
This form was created inside of Wisconsin Center for the Blind and Visually Impaired. Report Abuse - Terms of Service - Additional Terms