Vision and Hearing Screenings for Schools

How did you hear about this event or program?

First Name

Last Name

Job Title

School District If you are employed at a school please select the school district from the list select -- None or Not Listed --

School Building If you are employed at a school please select the school building from the list otherwise select -- None or Not Listed --

Phone

Phone Extension

What services are you requesting: RN assistance, screening day logistics, equipment for screenings, volunteers, all services listed