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Name:	*required
E-mail Address:	*required
Confirm E-mail Address:	*required
Name of Student served by CBVI:	*required
Student's Home School District:	*required
School Student attend:	*required
Telephone Number:	- - Ext: *required
(should we need to contact you)

Workshop attending: (Check one only): *required

Wednesday, October 16, 2013
1.	Middle School Low Vision/Large Print (4-8)
2.	High School Low Vision/Large Print (9-12)
3.	Middle School Braille (5-8)
Thursday, October 17, 2013
4.	Preschool-3 Low vision / large print
5.	Preschool-K Braille
6.	Elementary Braille (1-4)
7.	M.D. Low Vision