Register for a Community Vision Event

Section 1

Event Registration

Select the Community Vision Event *

Participant Type *

Child (Ages 5–17)

Adult (18+)

Section 2

Participant Information

First Name *

Last Name *

Date of Birth

Age

Gender

Race

Ethnicity

Primary Language

Veteran Status

LGBTQ+ Identity (Optional)

Disability Status (Optional)

Section 3

Parent/Guardian Information

Parent/Guardian Name

Relationship to Participant

Phone Number

Email Address

Street Address

City

State

ZIP Code

Preferred Method of Communication

PhoneText MessageEmail

Section 5

Vision History

Section 6

Insurance Information (Optional)

Prime Focus Inc. will not bill your insurance, and your insurance status will not affect your eligibility to receive services.

Does the participant currently have vision insurance?

Yes

No

Unsure

Medical Insurance Provider (Optional)

Section 7

Community Resource Interests (Optional)

Section 8

How did you hear about this event?

Section 9

Consents & Authorizations

Consent to Participate (Required)

I authorize Prime Focus Inc. and its licensed healthcare partners to conduct a vision screening and, if applicable, provide information regarding recommended follow-up care.

Photo & Video Release

I grant permission for Prime Focus Inc. to photograph or record me and/or my child during the event for educational, promotional, fundraising, and marketing purposes.

Communication Authorization

I authorize Prime Focus Inc. to contact me by phone, email, and/or text message regarding event updates, follow-up information, community resources, and future Prime Focus programs.

Acknowledgement (Required)

I certify that the information provided is true and accurate to the best of my knowledge.

Electronic Signature *

Printed Name

Date

Registration Form