CCNFBW New Member Information

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We are so thrilled that you have decided to become a member of the National Federation of the Blind of Washington . The Clark County chapter would like to extend a warm welcome to you. To help us learn more about you, please fill out this form. It will also help us to provide you with any support you need from us. Thank you for your time. We look forward to getting to know you. If you need help filling out this form, please contact our Membership chair person, Nikki Palm. She would be happy to help.

Email: nikkirae83@gmail.com
Phone: 360-703-8641

First Name: *

Last Name: *

Email Address: *

Home Phone Number: (Please include area code)

Mobile Phone Number: (Please include area code)

Street Address: *

Apartment or Suite number:

City: *

State: *

Zip Code: *

Birthdate:

MM/DD/YYYY

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