Mobile Vision Clinic Request Form

Mobile Vision Clinic Request Form

Please complete the form below.
Thank you for your interest in reserving the Mobile Vision Clinic! Please complete this form to help us plan and schedule your tour stop effectively. Each tour stop is 4 hours long and can accommodate up to 20 children per session depending on services (screenings vs exams) and age of children. Please note, we aim to service as many children as we can, however our primary goal is to maintain the integrity of our services by providing thorough and quality services. As such, the number of children that can be seen, will vary.
Point of Contact*

First NameLast Name
Event or School Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Email*
example@example.com
Approx. Number of Kids *
Age Range*
We only service kids ages 3-18
Approx. Age Range *
We only service kids ages 3-18
Please select your requested date and time

Note: "Tour Stops" are 4hrs long and conducted between 9am-1pm on weekdays for schools and from 3pm-7pm for afterschool programs. We service community organization and churches on weekends beginning as early at 8am.
Requested Tour Stop Date & Time*
To ensure our services remain free to families, we require a minimum donation in the amount of $2,500 from the host organization or school to cover the cost associated with vision screenings, eye exams, and the production of eye glasses (as needed). From time-to-time other organizations/companies will sponsor tour stops and we are able to pass along this sponsorship. These sponsorships are not guaranteed and are limited. Will you/your organization be making a tax-deductible donation to help cover the cost of services?

YesNo; would like to be considered for sponsorship
Do you have any special request?
Important Information

Please ensure the selected location has adequate space for our 35ft mobile clinic to park and set up. Our team will confirm your request and contact you upon review of this form to schedule your tour stop
Should be Empty:

Mobile Vision Clinic Request Form

Please select your requested date and time

Important Information