Participant Registration Form

If you would like to be an athlete in the ENVISION Blind Sports program please fill out the application so we can keep you updated on events.

Please complete the form below

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Phone

Numbers only. No dashes.

Date of Birth

MM

DD

YYYY

School Name

Grade

Vision Teacher Name

First Name

Last Name

Vision Teacher Email

Parent or Guardian Name

Required if under 18

First Name

Last Name

Parent or Guardian Address

If different from above

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent or Guardian Email

Parent or Guardian Phone

Numbers only. No dashes.

Specific activities you would like to participate in?

Check all that apply.

Sports Camp

Sports Clinics

Outdoor Adventures

Vision?

B1 - totally blind

B2 - best corrected vision is 20/600 and up

B3 - best corrected vision is 20/200 - 20/599

B4 - best corrected vision is 20/70 - 20-199

Description of Visual Impairment

What is the name of the visual impairment condition?

Additional Disabilities and/or Medical Conditions?

Emergency Contact Name

First Name

Last Name

Emergency Contact Relationship

Emergency Contact Phone

Numbers only. No dashes.

Participant Registration Form

If you would like to be an athlete in the ENVISION Blind Sports program please fill out the application so we can keep you updated on events.

Please complete the form below

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