NFB of Louisiana

Full Name
Street Address
City State Zip
Phone Number          Cell Phone
Email Address
Are you an NFB Chapter Member?
Yes No, but I would like to join No
Are you paying chapter dues at this convention? Yes No
Check all that apply:
Parent of a Visually Impaired Child Teacher/Para-Professional of Visually Impaired Children Blind Student	Blind/Visually Impaired Senior Rehabilitation Counselor Other
Would you like to receive any of the following free literature from the National Federation of the Blind?
Braille Monitor No, Thanks Braille Large Print
Future Reflections No, Thanks Braille Large Print
Would you like to sign up for NFB-NEWSLINE services? Yes, sign me up No, thanks No, I'm already signed up
Please select meal type (if you are paying for a banquet ticket): (Choose one) Regular Banquet Vegetarian Banquet
Preferred Agenda Format (Choose One) Braille Large Print Electronic (CD)
Is childcare needed? Yes No
If yes, enter name(s) and age(s) of child(ren): Name(s) and age(s) of child(ren) (please include any special needs)
Do you need transportation to the convention? (Choose One) No, thanks Yes, I need transportation
Is this your first NFBL State Convention? Yes    No
If yes, who invited you?
Make checks payable to: National Federation of the Blind of Louisiana. Payment must be received by April 3, 2009. When you click "Pay with a Check" the print dialog box will pop up--please print out this form and mail it in along with your payment. National Federation of the Blind of Louisiana Attn: State Convention Pre-registration 101 S Trenton St Ruston, LA 71270 Convention Pre-Registration      $15.00  Banquet Ticket                             $20.00 NFBL Chapter Dues                    $3.00 Hotel reservations must be made with Crowne Plaza by calling 225-925-2244. Convention rates of $83 per night (plus tax) cannot be guaranteed after March 30th.