CPS Student Virtual Career Fair Registration

Student Name*

First

Last
Date of Birth*

Month

Day

Year
Email*
Address*

ZIP / Postal Code
Phone*
Gender*
Parent/Guardian Name*

First

Last
Parent/Guardian Phone*
Parent/Guardian Email*
School*
Graduation Year*
Teacher of the Visually Impaired

First

Last
Teacher of the Visually Impaired Email
O&M Instructor

First

Last
O&M Instructor Email
Diagnosed Vision Impairment*
Preferred Reading Medium*
Publicity Release*
- Yes
- No
I hereby authorize and give permission for the participant’s name, photograph, video and/or other identifying information (such as age, eye condition, etc.) to be used by The Chicago Lighthouse for publicity, collaborative or training purposes. I understand such uses may include brochures, newsletters, website entries, press releases or written stories without payment or any other compensation. I further understand some uses may be for information and material sent to other organizations/companies (newspapers, television, radio, conference presentations, etc.) and that the materials will become the property of The Chicago Lighthouse and will not be returned.
Name

This field is for validation purposes and should be left unchanged.