At Large Chapter Membership Registration Form

Our state wide at large chapter is a great networking tool for blind and visually impaired people throughout Illinois. Dues are $2 per year. We meet via Zoom each month on the first Sunday at 7:00 pm.

For more information, please contact:
David Meyer, President
Phone: 708-606-7091
Email: datemeyer@mysero.net

Current Contact Information
Payment
Complete

At Large Chapter Membership Application

The payment total of $2 will appear on the second page under confirmation.

Contact 1

First Name First Name

Last Name Last Name

Street Address Street Address

Street Address Line 2 Street Address Line 2

City City

State/Province State/Province

Postal Code Postal Code

Phone Number Phone Number

Mobile Phone Number Mobile Phone Number

Email Email

Membership Status Membership Status

Are you blind/vision impaired? Are you blind/vision impaired?

Are you a parent of a blind child? Are you a parent of a blind child?

Are you a blind parent? Are you a blind parent?

Are you a blindness professional? Are you a blindness professional?

Please designate which area of profession you work in

Other Other

Are you a guide dog user? Are you a guide dog user?

Do you use a white mobility cane? Do you use a white mobility cane?

Birth Date Birth Date

Prefered Media Format Prefered Media Format

Prefered Contact Method Prefered Contact Method

Payment Information
Total	$ 0.00

At Large Chapter Membership Registration Form

At Large Chapter Membership Registration Form

At Large Chapter Membership Application

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