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Volunteer Enrollment Form
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*
Alabama
Alabama
Alaska
Alaska
Arizona
Arizona
Arkansas
Arkansas
California
California
Colorado
Colorado
Connecticut
Connecticut
Delaware
Delaware
District of Columbia
District of Columbia
Florida
Florida
Georgia
Georgia
Hawaii
Hawaii
Idaho
Idaho
Illinois
Illinois
Indiana
Indiana
Iowa
Iowa
Kansas
Kansas
Kentucky
Kentucky
Louisiana
Louisiana
Maine
Maine
Maryland
Maryland
Massachusetts
Massachusetts
Michigan
Michigan
Minnesota
Minnesota
Mississippi
Mississippi
Missouri
Missouri
Montana
Montana
Nebraska
Nebraska
Nevada
Nevada
New Hampshire
New Hampshire
New Jersey
New Jersey
New Mexico
New Mexico
New York
New York
North Carolina
North Carolina
North Dakota
North Dakota
Ohio
Ohio
Oklahoma
Oklahoma
Oregon
Oregon
Pennsylvania
Pennsylvania
Puerto Rico
Puerto Rico
Rhode Island
Rhode Island
South Carolina
South Carolina
South Dakota
South Dakota
Tennessee
Tennessee
Texas
Texas
Utah
Utah
Vermont
Vermont
Virginia
Virginia
Washington
Washington
West Virginia
West Virginia
Wisconsin
Wisconsin
Wyoming
Wyoming
Armed Forces (the) Americas
Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Europe
Armed Forces Pacific
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
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
Alabama
Alabama
Alaska
Alaska
Arizona
Arizona
Arkansas
Arkansas
California
California
Colorado
Colorado
Connecticut
Connecticut
Delaware
Delaware
District of Columbia
District of Columbia
Florida
Florida
Georgia
Georgia
Hawaii
Hawaii
Idaho
Idaho
Illinois
Illinois
Indiana
Indiana
Iowa
Iowa
Kansas
Kansas
Kentucky
Kentucky
Louisiana
Louisiana
Maine
Maine
Maryland
Maryland
Massachusetts
Massachusetts
Michigan
Michigan
Minnesota
Minnesota
Mississippi
Mississippi
Missouri
Missouri
Montana
Montana
Nebraska
Nebraska
Nevada
Nevada
New Hampshire
New Hampshire
New Jersey
New Jersey
New Mexico
New Mexico
New York
New York
North Carolina
North Carolina
North Dakota
North Dakota
Ohio
Ohio
Oklahoma
Oklahoma
Oregon
Oregon
Pennsylvania
Pennsylvania
Puerto Rico
Puerto Rico
Rhode Island
Rhode Island
South Carolina
South Carolina
South Dakota
South Dakota
Tennessee
Tennessee
Texas
Texas
Utah
Utah
Vermont
Vermont
Virginia
Virginia
Washington
Washington
West Virginia
West Virginia
Wisconsin
Wisconsin
Wyoming
Wyoming
Armed Forces (the) Americas
Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Europe
Armed Forces Pacific
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
Second Office Location ZIP code
Second Office Location Email
Languages Spoken*
I am unable to see children under the age of.
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All Children See is not a program for people 18 and over.
Please, check our
other resources.
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