Membership Application

Silicon Valley Council of the Blind

SVCB Membership Application Form and Instructions

rev. 05/22/22 (New fields of info for CCB)

Instructions

Complete the application form that follows and submit it, along with the appropriate dues (see below), to:

Silicon Valley Council of the Blind

P.O. Box 4116, San Jose, CA 95125

Cash should not be used unless hand-delivered to the membership chairperson.

Dues

$20 per calendar year with the following exceptions:

$10 per year for members where SVCB is not their home chapter (the other chapter pays to CCB).

$10 for life members of CCB (contact CCB at 800-221-6359 about this designation).

$30 for a two-year membership initiated July 1–December 31 (for the remainder of the current year plus all of the next year).

Note: Multiple years' dues can be paid at any time.

Thank you for wanting to become a member of SVCB.

For more information about SVCB and the great benefits of membership, please email membership@svcb.cc. In addition, use that email address to request application forms in large print and braille.

TITLE: _______

NAME: _________________________________________________________

STREET ADDRESS: _____________________________________________

________________________________________________________________

CITY: __________________________________________________________

STATE: ______ ZIP CODE: ______________________

PRIMARY PHONE: _________________________

ALTERNATE PHONE: _________________________

EMAIL ADDRESS: ______________________________________________

Can your information be published (Y/N)? ____

Emergency Contact Person: ____________________________________

Emergency Contact Phone #: _________________________

Your Identified Gender: _________________________

Your Identified Race/Ethnicity: _____________________________________

BIRTHDAY (MONTH; DAY; YEAR): ______________________

VISION STATUS (LB - LEGALLY BLIND, VI - VISUALLY IMPAIRED, FS - FULLY SIGHTED): ______

PUBLICATIONS FORMAT:

(B - BRAILLE, E - EMAIL, L - LARGE PRINT)

SVCB IN TOUCH: ____

BLIND CALIFORNIAN: ____

BRAILLE FORUM: ____

MEETING REMINDER:

Do you want to be contacted monthly about the meeting and news items (Y/N)? ____

If 'Yes' provide a phone number and/or email address as needed:

__________________________________________________________

OTHER CCB CHAPTER MEMBERSHIP:

If you currently belong to any other chapter of the California Council of the Blind, give the chapter name:

________________________________________________________________

Are you a CCB Life Member? _________

Are you an ACB Life Member? _________

MISCELLANEOUS: (OCCUPATION, SPECIAL INTERESTS, ORGANIZATIONS, etc.):

__________________________________________________________________________________________________________