Full Name:      
Title:          
Group/Agency:   
Address:        
City/State/Zip: 

Home Phone:     
Work Phone:     

E-mail address (e.g. jdoe@myisp.com)
                

I would like to receive a sample issue of the MAPVI newsletter,
   The Sighted Guide

I would like to be contacted by a MAPVI parent representative in my vicinity.

I would like a MAPVI representative to contact me.

I want to become a MAPVI member. Enclosed is my check for $15.00
   payable to MAPVI.

   Check one:
   Parent/Guardian (full membership)
   Visually Impaired Adult (full membership)
   Extended Family/Friend (associate membership)
   Professional (associate membership)
   Group/Agency (associate membership)
   Professional (associate membership), Perkins School
      for the Blind (Note that no dues are required if your address
      listed above is for Perkins or one of its Outreach offices).