ACB Minnesota New Member SignUp

Welcome to ACB of Minnesota. Please use the form below to sign up. Some one will be in touch with you shortly to help acquaint you with our services and your fellow blind and low vision brothers and sisters.

Join ACB of Minnesota

Name*
First Last
Email*
Home Phone*
Cell Phone
Address*
Street Address Address Line 2 City State ZIP Code
Vision*
Which of the following would you identify as?
- Degree of eye sight? Blind
- Low Vision
- Fully Sighted
Gender*
- Gender? Prefer Not To Answer
- Female
- Identify As Female
- Male
- Identify As Male
- Nonbinary
- Other
Ethnicity*
- Race? Prefer Not To Answer
- Multi-Racial / Multic-Ethnic
- Asian
- Black / African American
- Hispanic / Latino
- Middle Eastern / North African
- Native American / Alaskan Native
- Native Hawaiian / Pacific Islander
- South Asian
- White / Anglo-Saxon
- Other
Birthday
Optional
Age
Optional
- Age Range? Under 30
- 30 to 49
- 50 to 65
- 65 plus
Do you wish to receive the Braille Forum Magazine?*
- Want to receive The Braille Forum? No
- Yes: In Braille
- Yes: In Large Print
- Yes: Via Email
- I Already Receive It
Optional
- Add $1 to help us cover Square’s credit card charges.

Credit Card*

Cardholder Name

Card Details

Membership Fee*
Price:
Credit Card Cover Charges*
Price:
Total
$0.00
We use Square to securely process transactions and payments.
Phone
This field is for validation purposes and should be left unchanged.

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