Event Pre-Registration
Join us for a day dedicated to the health of those who served. We are offering free vision screenings, health checks, VA benefit consultations, and MORE!
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Arrival Time
Please Select
9:00AM - 10:00AM
10:00AM - 11:00AM
11:00AM - 12:00PM
12:00PM - 1:00PM
1:00PM - 2:00PM
2:00PM - 3:00PM
Are you a US Veteran?
Yes
No (Family Member/Community)
Do you have a copy of your DD214?
Yes, I will bring it with me.
No, I need help requesting it.
N/A, Not a Veteran
Requested Services (Check all that apply)
Eye Exam & Glasses (Limited to 150)
Health Screening
VA Benefits Consultation
Donate Blood
I am bringing others with me (how many)
Housing Status (Confidential): We have resources on-site to assist with housing.
I have stable housing
I am experiecing housing instablity
Prefer not to say
Please share my contact info with event partners so I can receive information about job opportunities and community resources.
Yes!
No.
Enter me into the Pre-Registration Raffle! I understand I must check in at the event to be eligible to win.
Yes!
No.
Please provide any assistance / mobility needs requests (optional)
By submitting this pre-registration form I understand that vision appointments are first-come, first-served. I agree to bring relevant documents if available. I authorize Stable Able to share my registration information with event partners for the purpose of treatment. I understand that glasses are custom-made and will be mailed to the address provided.
*
Yes, I agree.
Submit
Should be Empty: