KidSight’s Vision Assistance Application Child's Name(Required) Child's Birthdate(Required) MM slash DD slash YYYY 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? 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 Name PhoneDate of last eye exam MM slash DD slash YYYY Parent/Guardian SignatureConsent(Required) I agree(Required)I give KidSight permission to access information about my child’s vision care. This includes (but is not limited to) information on: scheduled eye appointments, vision diagnosis and vision treatment. I understand that KidSight will only use this information for the purposes of evaluating the vision screening and that all information will be kept confidential.Parent Signature(Required) Digital Signature CAPTCHA Δ
