Vision Initiative Pilot Project Registration

Thank you for registering your interest in the Vision Initiative Pilot Projects

In 2013-2015 the Vision Initiative will deliver concentrated health promotion activity to the four local government areas of Darebin, Greater Geelong, Greater Shepparton and Latrobe through pilot projects on eye health and vision care.

To register your interest and involvement in the pilot projects please complete your details below.

A member of the Vision Initiative team will be in contact with you to discuss the pilot projects further.

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* 1. Organisation Address

Name: *

Company: *

Address 1:

Address 2:

City/Town: *

State/Province:

ZIP/Postal Code: *

Email Address:

Phone Number (work/mobile): *

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* 2. What is your preferred method of contact?

Telephone (work)

Telephone (Mobile)

Other (please specify)

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* 3. When is it best to contact you?

Weekdays - morning

Weekdays - afternoon

Weekdays - evening

Weekend

Other (please specify)

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* 4. Which best describes the services provided by your organisation.

Pharmacy

Optometry

Ophthalmology

Other (please specify)

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* 5. Which local government area do you work in?

Darebin

Greater Geelong

Greater Shepparton

Latrobe

Other (please specify)

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* 1. Organisation Address

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* 2. What is your preferred method of contact?

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* 3. When is it best to contact you?

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* 4. Which best describes the services provided by your organisation.

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* 5. Which local government area do you work in?

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* 6. How many health professionals do you have working in your organisation?