Please fill out the form below. Required fields are marked with asterisks (*). Your completed form will be reviewed to determine your eligiblity. If you are qualified, you will be contacted. Verification may be requested.

If you prefer a printable version click here. (Requires Adobe Acrobat Reader)

The privacy of your information is very important. This form is fully secured and your information is protected.

Parent Name: *  
Address: *  
City: *  
State: *  
Zip: *  
Home Phone: *  
Email Address: *  
Social Security Number:
(required if child does not have one)
 
Does this Child have private or government insurance, Medicaid or Medicare (OHP) that covers exams? *  



Is anyone in your household currently working at least part-time? *  



What is the total number of people in your household living with you, including yourself? *  
What was your household's approximate gross income (before taxes and deductions) including income from other sources such as alimony and child support?  

Please enter whole dollar amount only.
Last month:       $

OR Last year:    $

How would you prefer to be contacted?  


     
School Name: *  
School Address Information: *  
Contact Name: *  
Title: *  
School Phone: *  
County: *  
     
First Name: *  
Last Name: *  
Date of Birth: *  
Social Security Number: *  
Date of last eye exam: *  
Please list any other circumstances that limit your access to vision care (i.e. transportation)