Welcome! If you are an educator and you think a student could benefit from the BSBG program for children 13 or younger, please complete the form below.** Note: Parents, please do not fill out the form as you will need an educator's referral for the application.
Submit your request below and allow us to get back to you within 3 to 4 weeks. Please also check your Provincial Coverage regulations before submitting this form to see if your student is covered. Although we wish to help as many students as we can, due to the volume of request, no more than 3 students from the same school will be accepted into this program per year. Thank you!
Student's first name
*
Student's last name
*
City
*
Ex. Calgary
Community name
Bow Valley/Edgemont in Calgary, etc.
School name
*
School phone number
*
Example: 999-999-9999
Province/Territory
*
Please Select
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Student's grade
*
What is the child's grade level?
Your first name (educator)
*
Your last name (educator)
*
What subjects do you teach?
*
Your email (educator)
*
example@example.com
Which FYidoctors location is closest to you? Click the link below to find a location.
*
https://fyidoctors.com/pages/find-a-location
Share with us why you think this child/student would benefit from receiving eye care and eye wear from our BSBG program. All responses remain confidential.
*
How did you hear about the BSBG program?
*
Social network post? Ad? Word of mouth? From your School?
Submit
Should be Empty: