Volunteer Enrollment Form

Name*

First Name

Last Name

Credentials

AAPOS Member ID*

Email*

I was referred by:

Terms*

I volunteer to provide a comprehensive, medical eye exam and treatment to children (US legal residents/citizens under age 18) and follow-up care for up to one year for any condition diagnosed during the initial exam—at no cost to ACS patients. If ACS treatment needed is beyond the scope of your services, such as potential surgical fees or other complex treatments, volunteers agree to contact ACS@AAPOS.org for assistance. I volunteer to provide care at the following practice address.

Office/Clinic name

Street

City*

State*

ZIP Code*

Office email

Contact First name

Contact Last name

Phone*

Fax

Second Office Location Office/Clinic name

Second Office Location Street

Second Office Location City

Second Office Location State

Second Office Location ZIP code

Second Office Location Email

Languages Spoken*

I am unable to see children under the age of.