At Large Chapter Membership Form

Our state wide at large chapter is a great networking tool for blind and visually impaired people throughout Michigan. Dues are $6 per calendar year. We meet via Zoom each month.

For more information contact:
Robert E. Parsons, Jr., Coordinator
Phone: 804-801-7674
Email: robert.e.parsons@wmich.edu

This form can only be submitted for residents of Michigan. If you are not a resident of Michigan, then please do not submit this form. Dues are $6.00 per calendar year.

After completing this form, you will be redirected to the form's confirmation page on which you will find a PayPal button to pay your membership dues.

All required fields are marked with a *.

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Home Phone Number

Please format phone numbers by using the format of area code, hyphen, next three digits, hyphen, last four digits (ex: 123-456-7890)

Cell Phone Number

Please format phone numbers by using the format of area code, hyphen, next three digits, hyphen, last four digits (ex: 123-456-7890)

Email Address *

By checking the checkbox below, I understand that this membership form is for the National Federation of the Blind of Michigan's At Large Chapter *

I accept

Membership Status *

Are you blind or vision impaired? *

Are you a parent of a blind child? *

Are you a blind parent? *

Are you a blindness professional? *

Please designate which area of profession you work in *

Orientation & Mobility Instructor

Teacher of Blind Students

Rehabilitation Instructor

Other

Please designate which area of profession you work in Other

Are you a guide dog user? *

Do you use a white mobility cane (i.e. NFB white cane)? *

Date of Birth

Month

Day

Year

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