Volunteer Enrollment Form

Name*

First Name

Last Name

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 disease diagnosed during the initial exam—at no cost to ACS patients. * I volunteer to provide care at the following practice address *

Address Line 1*

Address Line 2

City*

State*

ZIP Code*

Office email

Contact First name*

Contact Last name*

Phone*

Fax

Second Office Location Address Line 1

Second Office Location Address Line 2

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.