Permission for Glasses Program Participation
Please complete this application to receive a free pair of glasses through KidSight and Keralink. This form also connects families to information about no-cost exams and other resources for low-income households.
Contact Information
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Parent/Guardian Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Phone
*
Please enter a valid phone number.
Parent/Guardian Email
*
example@example.com
Child's Ethnicity
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Multiple ehtnicity
Prefer not to answer
Insurance/Income Information
Does your child have vision insurance?
*
Yes
No
Is this the child's first-time wearing glasses?
*
Yes
No
Number of persons in the household
*
Annual Household Income
*
Glasses Prescription Information
Upload a copy of your child's glasses prescription.
*
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Parent/Guardian Consent and Signature
By signing below, I confirm that the information I have provided is true and accurate to the best of my knowledge. Please check the boxes to consent to: 1. sharing your child’s prescription information only for the purpose of ordering glasses, and 2. allowing KidSight to share the impact of this program through photos of your child after receiving their glasses. I understand that I may withdraw this consent at any time by giving written notice to KidSight, except where actions have already been taken.
I give permission for:
*
KidSight to share necessary information about my child (including prescription information) with KeraLink International solely for the purpose of ordering and securing glasses for my child.
I give permission for:
KidSight to use my child’s photo or video in promotion and marketing. I understand that participation in the free glasses program is still allowed if I don’t consent.
Signature
*
Please verify that you are human
*
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