Silver BELLS Registration

We’re excited you’ve chosen to take the first step in joining us!

We just need to collect a few details to better help us learn a little bit about you. After you register, we'll schedule an informal intake interview to get to know you better.

If you run into any issues, please contact the program coordinator, Sandy Halverson by phone at: (703) 400-6890, or by email at: silverbells@nfbv.org.

Items marked with a * are required fields.

Registration Form

1 Start 2 Complete

Full name: *

Street address: *

Unit or apartment number: (optional)

City: *

State:

Zip code: *

Preferred phone number: *

Is this your work, home, or cell number? *

Email address: *

Preferred method of contact: *

Preferred language: *

Date of birth: (MM/DD/YYYY) *

Name something you don’t know how to do as a blind person that you would like to know by the end of the program. *

Are you familiar with the Zoom platform? *

If using a phone to dial into Zoom, please provide the number from which you'll be calling:

Tell us about your blindness: *

A family member will be attending with me: *

If yes, provide the family member’s name:

What is their relationship to you?

This helps us make hotel room assignments.

Do you have a disability other than blindness? Please describe.

For white cane measurement purposes, what is your height? *

Do you have any food allergies of which we should be aware? *

If selected for this program, will you need transportation? *

Do you have a Windows computer at home? *

Are you an Android or iPhone user? *

Leave this field blank

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Silver BELLS Registration

Registration Form

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