VISION START APPLICATION

Is the child you are applying for age 4-7? *

Based on the number of people in your family, is your total family income at or below the amount shown in the chart below? *

Number of people in your family	Total Family Income
2	$54,930
3	$69,090
4	$83,250
5	$97,410
6	$111,570
7	$125,730
8	$139,890

*For families/households with more than 8 persons, add $4,720 for each additional person.

Congratulations!

Based on your answers, your child is eligible for the Vision Start Program! Please answer a few questions to complete your application.

Parent/Guardian Information

First Name *

Last Name *

Address *

City *

US States *

ZIP Code *

Phone Number *

Email Address *

Child Information

First Name *

Last Name *

Date of Birth *

Child must be between 4-7 years old

Vision Insurance Coverage (if none write N/A) *

Additional Information

How did you hear about us? *

Provider Selection

Which eye doctor would you like to schedule an appointment with? (Please contact the clinic to schedule your child's eye exam and make sure to reference the Vision Start Program).

Select City *

Select Practice *

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Select Provider *

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VISION START APPLICATION

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Parent/Guardian Information

Child Information

Additional Information

Provider Selection

Not Eligible

Not Eligible

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