KidSight’s Vision Assistance Application Δ 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)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 Medicaid?(Required) Yes No If yes, which Medicaid plan does applicant utilize?Home State HealthShow Me Healthy KidsUnited HealthcareHealthy BlueUnknownDoes 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)How much income does your whole household earn in 12 months? Include wages, tips, government help, and any other income."Vision Care InformationEye Doctor's NamePhoneDate of last eye exam MM slash DD slash YYYY Parent/Guardian SignatureAcknowledgment of Assistance(Required) I agree(Required)I understand that submitting this application does not guarantee that my child will receive financial assistance, an eye exam, glasses, or other services. Eligibility and available assistance will be determined based on program requirements, available funding, and provider availability.Care Coordination Authorization(Required) I agree(Required)I authorize KidSight to communicate with participating schools, healthcare providers, eye care providers, clinics, and assistance programs as reasonably necessary to coordinate vision care and determine available assistance for my child.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
