KidSight’s Vision Assistance Application Child's Name(Required)Child's Birthdate(Required) MM slash DD slash YYYY Gender(Required)MaleFemaleOtherPrefer Not to AnswerEthnicity(Required)American Indian or Alaskan NativeAsian / Pacific IslanderBlack or African AmericanHispanicWhite / CaucasianMultiple ethnicityOtherPrefer Not to AnswerChild's Grade(Required)NurseryToddlerPreschoolKindergarten1st grade2nd grade3rd grade4th grade5th grade6th grade7th grade8th grade9th grade10th grade11th grade12th gradePlease select your child’s current grade. If your child is between grades, choose the grade they will be entering.Parent/Guardian Name(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email(Required) Phone(Required)Preferred Method of Contact(Required) Phone Email Text Message Assistance Requested for...(Required) Eye Exam Eye Glasses Replacement Glasses Check all that applyInsurance/Income InformationHas the applicant had an eye exam in the last 12 months?(Required) Yes No What is the name of your eye doctor?Has Your Child Worn Glasses Before?(Required) Yes No Does the applicant have health insurance?(Required) Yes No If yes, what is the name of your insurance provider?Does the applicant have vision insurance?(Required) Yes No Does applicant qualify for free/reduced lunch?(Required) Yes No N/A Does applicant attend Head Start?(Required) Yes No Number of Persons in Family/Household(Required)12345678+Annual Household Income(Required)Vision Care InformationEye Doctor's NamePhoneDate of last eye exam MM slash DD slash YYYY Parent/Guardian SignatureConsent(Required) I agree(Required)I authorize my child’s eye care provider(s) to disclose information about my child’s vision care to KidSight. This may include, but is not limited to: scheduled eye appointments, vision prescriptions, diagnoses, and treatment plans. I also authorize KidSight to share this information, as needed, with partner providers such as KeraLink for the purpose of assisting my child in obtaining glasses I understand that: - This authorization will remain in effect for one year from the date signed, unless I revoke it in writing sooner. - I may revoke this authorization at any time by providing written notice to KidSight, except to the extent that action has already been taken. - All information will be kept confidential to the extent permitted by law.Consent(Required) I agree(Required)I give permission for KidSight to use photos, videos, or other likenesses of my child in promotional materials, social media, or other communications related to the program. I understand that photos may be shared with partners such as KeraLink. Parent Signature(Required) Digital Signature CAPTCHA Δ
