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Adult Vision Screening and HealthyEyes Webinar Wednesday, May 24, 2023, 10:00 am to 12:30 pm
Registration-May 24, 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
(Required.)
Ms.
Miss
Mrs.
Mr.
Dr.
none
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2.
First Name
(Required.)
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3.
Last Name
(Required.)
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4.
Home Address
(Required.)
Street Address
Apt#
City
State
Zip Code
Ohio County
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5.
Work phone number
(Required.)
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6.
Home or Cell Phone number
(Required.)
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7.
Preferred E-mail address
(Required.)
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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.
(Required.)
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9.
Work Address
(Required.)
Organization
Address
City
State
Zip Code
Ohio County
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10.
Once you complete training, are you willing to be contacted to provide vision screenings in your area?
(Required.)
Yes
No
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11.
Have you been certified as an adult vision screener by Prevent Blindness in the past?
(Required.)
Yes
No
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12.
If yes, are you taking this class to re-certify?
(Required.)
Yes
No
Other (please specify)
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13.
If yes, do you have the near and distance charts as well as Registration/Risk Assessment Forms?
(Required.)
Yes
No
Other (please specify)
14.
Questions or comments
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