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

Question Title

* 1. Preferred Salutation

Ms.

Miss

Mrs.

Mr.

Dr.

none

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* 2. First Name

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* 3. Last Name

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* 4. Home Address

Street Address

Apt#

City

State

Zip Code

Ohio County

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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

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?

Yes

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

Yes

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

Yes

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?

Yes

Other (please specify)

Adult Vision Screening and HealthyEyes Webinar Wednesday, May 24, 2023, 10:00 am to 12:30 pm

Registration-May 24, 2023

Question Title

* 1. Preferred Salutation

Question Title

* 2. First Name

Question Title

* 3. Last Name

Question Title

* 4. Home Address

Question Title

* 5. Work phone number

Question Title

* 6. Home or Cell Phone number

Question Title

* 7. Preferred E-mail address

Question Title

* 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.

Question Title

* 9. Work Address

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

* 14. Questions or comments