Lions 2E2 Clubs Vision Screening Request Form

This 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 * Required
First Last
Phone * Required
Email * Required
Lions 2E2 Club Name * Required
I am requesting to schedule a Lions Club District 2E2 Vision Screening for my Club * Required
- Yes
Screening Event Contact Name * Required
Screening Event Contact Email * Required
Screening Event Contact Phone * Required
Vision Screening Address * Required
Street Address Address Line 2 City State ZIP Code
1st Choice Date - must be mm/dd/yyyy format * Required
Date Format: MM slash DD slash YYYY
1st Choice Time * Required
: HH
MM
AM/PM
2nd Choice Time * Required
: HH
MM
AM/PM
2nd Choice Date - must be mm/dd/yyyy format * Required
Date Format: MM slash DD slash YYYY
1st Choice Time * Required
: HH
MM
AM/PM
2nd Choice TimeTime * Required
: HH
MM
AM/PM
3rd Choice Date - must be mm/dd/yyyy format * Required
Date Format: MM slash DD slash YYYY
1st Choice Time * Required
: HH
MM
AM/PM
2nd Choice Time * Required
: HH
MM
AM/PM
Please list equipment requested for your Vision Screening Event. * Required
Are you requesting the Board's assistance? * Required
- Yes
- No
Please 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.
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Comments
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