Tell us about your cute kid!
In order to get a better understanding of your child and your family, please complete the following questions.  This will primarily be used to see if you meet the qualifications for our free glasses program.
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Child's Name *
Child's Date of Birth *
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Your Name *
Email *
Phone number *
Tell us about your child, who they are and why they need glasses? *
Does your child also need an eye exam?
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Do you have vision insurance? *
Does your child or any children in your family qualify for Free & Reduced Lunch at school? *
How frequently are you normally buying glasses (include all kids in family, ex. 2 kids each needing glasses once per year = 2 times/year)? *
Are there special circumstances or reasons for your interest in this program? Can you tell us how new glasses would help your child/family? *
Income Table
Does your family's income fall at or below the table above? *
Do we have your permission to use your child's story or photo in promotional material for this program and Violet Sees in general? *
How did you hear about our program?
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