California Council of the Blind State Convention

California Council of the Blind State Convention
Friday October 2 through Sunday October 4
Student Information
Name (First and Last):*
Street Address*
City*
State*
Zip*
Phone Number:*
Alternate Phone Number
Email:*
Birth Date*

MonthDayYear
Gender

MaleFemale
What is your preferred accessible format? *

Large printBrailleElectronic Word Document
Do you use any mobility aids? If yes, please indicate:

White CaneDog GuideWheelchairOther
Are there any other accommodations you may need? If so, please specify:

For youth over the age of 18, please provide emergency contact information below. If you are under 18 years of age, please provide your parent/guardian information:
Parent / Guardian / Emergency Contact (Name: First and Last):*
Phone Number:*
Email:*
Relationship to participant:

Short Answer Questions
1. What level of education are you currently in?*
2. What are your educational goals and how are you achieving these goals?*
3. Why you would like to attend the California Council of the Blind’s Conference and Convention?*
4. What are three words you would use to describe yourself?*
5. What makes you stand out from the other candidates that are applying for this trip?*
6. What do you think is the most important issue facing the blind and low vision community*
7. Please tell us about a person you admire and explain why?*
Before submitting your application, please check the box below.
I have answered all of the questions in this application to the best of my knowledge. *

Agree
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