Childcare / Head Start Vision Care Form
Little Peeps provides eye exams and glasses FREE OF CHARGE to kids in need through a Vision Voucher system. Please complete this form to let Little Peeps know how we might be able to help in your community. For more information, visit www.mountainhealthgives.org or contact Executive Director Molly Severtson at molly@mountainhealthgives.org or 406-438-7187.
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Your Name *
Your Center's Name *
Your State
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Your Position *
Your Phone Number *
Your Email Address *
Does your center currently conduct vision screenings of students? *
If your center conducts vision screenings, at which ages and in what situations do they screen students?
Who conducts vision screenings at your center?
Does your school district do any type of follow-up to ensure that students are getting eye exams and glasses as needed following a vision screening? *
Are there programs to which you refer parents/guardians who have trouble accessing eye exams and/or glasses for their students?
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If so, which programs do you refer parents/guardians to?
Do you need help meeting the need for eye exams in your community? *
Are there enough eye doctors in your community to meet your students' vision care needs?
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Would you like someone to contact you about the Little Peeps program and how it could help meet the need for vision care in your community? *
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