Ray-Ban Meta AI Glasses Program Application

Ray-Ban Meta AI Glasses Program Application

Complete this application for VFW Department of Washington glasses support—approval isn’t guaranteed.
Applicant
First Name
Last Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Contact Method
Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Are you a Washington State resident?
Who are the glasses for?
Recipient Status
Military and VFW
Branch of Service
Service Status
Are you currently a VFW member?
VFW Post Number
Vision Eligibility
Eligibility Definitions
Vision Impairment Type
Diagnosed or Verified by a Qualified Professional
Cause of Vision Loss

Other
Does the Vision Loss Affect Safe or Independent Completion of Everyday Activities?
Verification and Use
If required, who can verify the vision impairment?
How may these glasses help?

Other
Briefly describe how these glasses could help the recipient
Does the applicant use a smartphone?
If yes, which type?
Willingness to participate in training/orientation
Distribution and Certification
Can you attend an in-person Washington distribution event if required?
If accommodation may be required, please briefly describe your accessibility needs.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Would you like information about other VFW Department of Washington programs and resources?
Should be Empty: