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PS/MS 5 VSP Vision Mobile Clinic Family Interest Form
PS/MS 5, Start Lighthouse, and VSP Vision’s Eyes of Hope program are partnering to provide free eye exams and glasses for eligible students at PS/MS 5 on Monday, September 28 and Tuesday, September 29, 2026.The clinic is available to students age 5 and older who may need access to vision care. Please complete this form by September 15, 2026, if you are interested in having your child participate.Submitting this form does not guarantee an appointment. PS/MS 5 will follow up with families whose children are selected for the clinic. Families will also need to complete and sign VSP’s required patient paperwork before their child can receive services.There is no cost to families for services provided through the clinic.
Student's Name
*
First Name
Last Name
Student's Birthdate
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Student's Grade
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Next Steps
PS/MS 5 expects to serve approximately 50 or more students each day. Because space is limited, completing this form does not guarantee that your child will receive an appointment.If your child is selected, the school will contact you and provide a VSP patient packet that must be completed and signed before your child can participate. The patient packet includes health history, consent, and VSP’s policies, including options related to photography and media.
I understand that submitting this form expresses my interest but does not guarantee my child an appointment.
I understand
I agree to complete the required VSP patient paperwork before the clinic.
I agree
Submit
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