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Registration-June 14, 2023

Please complete the registration information below and click the "Done" button.  For further information, contact Lauras@pbohio.org.
You will receive a Zoom link in your e-mail a week prior to the training

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* 1. Preferred Salutation

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* 2. First Name

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* 3. Last Name

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* 4. Home Address

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* 5. Work phone number

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* 6. Home or Cell Phone number

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* 7. Preferred E-mail address

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* 8. Job title, volunteer position, or student. If you are a student or volunteer put where you go to school or where you volunteer (or plan on volunteering.) Include the address and organization below.

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* 9. Work Address

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* 10. Once you complete training, are you willing to be contacted to provide vision screenings in your area?

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* 11. Have you been certified as an adult vision screener by Prevent Blindness  in the past?

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* 12. If yes, are you taking this class to re-certify?

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* 13. If yes, do you have the near and distance charts as well as Registration/Risk Assessment Forms?

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* 14. Questions or comments

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