Lions 2E2 Clubs Vision Screening Request FormThis page is intended only for use by Lions Club District 2E2 Clubs that are in the planning phase of scheduling a Vision Screening.→ If you an individual looking for a Vision Screening Schedule or needing Vision Assistance – please see LOEB Vision Assistance Program Pages.Please Note: An * means input is required.Name* First Last Phone*Email* Lions 2E2 Club Name*I am requesting to schedule a Lions Club District 2E2 Vision Screening for my Club* YesScreening Event Contact Name*Screening Event Contact Email* Screening Event Contact Phone*Vision Screening Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 1st Choice Date* MM slash DD slash YYYY 1st Choice Time* : Hours Minutes AMPM AM/PM2nd Choice Time* : Hours Minutes AMPM AM/PM2nd Choice Date* MM slash DD slash YYYY 1st Choice Time* : Hours Minutes AMPM AM/PM2nd Choice TimeTime* : Hours Minutes AMPM AM/PM3rd Choice Date* MM slash DD slash YYYY 1st Choice Time* : Hours Minutes AMPM AM/PM2nd Choice Time* : Hours Minutes AMPM AM/PMPlease list equipment requested for your Vision Screening Event.*Are you requesting the Board's assistance?* Yes NoPlease Note You have support through the 2E2 District, the Lions Organ and Eye Bank as well as through Prevent Blindness Texas. Plan to have a member from one of these organizations on hand for your first Children Vision Screening to help with the logistics and conducting the event. Plan your activity at least two months in advance so that you can confirm that the Plusoptix Vision Screeners are available for your Club’s use. Contact the LOEB for reserving the equipment. Local vision screening should be managed and performed by local Lions. The LOEB would help with the initial screening and training. I understand that Vision Screening instruments will be available on a first come-first served basis. The “Back to School” time is especially busy so plan these events in advance. Only Certified Screeners are authorized to use these instruments. I understand and agree that the requesting Lions Club is responsible for all reserved instruments and will be liable for any damage or loss of the equipment.CAPTCHANameThis field is for validation purposes and should be left unchanged.