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Get NE NCECBVI Fall Low Vision Clinic Registration Form 2018

Istration Deadline is October 4, 2018) This form must be completed by the school district s teacher of the visually impaired or staff member serving the child with a verified or suspected vision loss. Student Name: Gender: DOB: Age: Grade: Parent/Guardian Name(s): Parent Mailing Address (Street/PO Box, City, Zip): Parent Email Address: Parent Preferred Phone (+area code): School District: School Building: School Address (Street/PO Box, City, Zip): School Contact Person: Position: This.

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