Request a Screening

Please complete this form to request a screening for the children in your community.  Requests for screenings will be scheduled in the order they are received, so if there are specific dates you need please submit as early as possible to ensure availability of equipment.  We look forward to working with you!

Thank you! We will be contacting you soon to confirm your vision screening request.

Who is requesting a vision screening? *

 School

 Daycare Center

 In Home Daycare

 Health fair

 Lions Club Member

 Other

What equipment are you requesting?

 Vision Screening Equipment

 Vision Van and Screening Equipment

 Vision Van only

Screening Location *

Address (Street, City, State, Zip) *

Name of Person Requesting a Screener *

Phone # *

Email Address *

Request Dates (If known)

Age Range of Children Being Screened *

 1-3 yr olds

 4-6 yr olds

 Elementary age

 Middle School age

 High School Age

 All Ages

Estimated Number of Children Being Screened *

Have you had KIDSIGHT screen at this location before? *

 Yes

 No

Please tell us how you heard about Lions KIDSIGHT!

Other Information

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