Project Vision Aid - iPad Assistance Application

1. Child's Full Name: *

First Name

Last Name

2. Date of Birth (MM/DD/YYYY): *

MM

DD

YYYY

3. Parent/Guardian Name: *

First Name

Last Name

5. Mailing Address: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

11. Has your child used an iPad or tablet before? *

Yes

No

14. Does your child qualify for free or reduced-price lunch at school?

Yes

No

Prefer not to say

15. Does your child have access to assistive technology at school?

Yes

No

Prefer not to say

I, the undersigned, consent to provide the information in this form to The Vision of Children Foundation for the purposes of evaluating my child’s eligibility for the Vision Aid iPad Program. I understand that: *

• This application does NOT guarantee that The Vision of Children Foundation will be able to provide an iPad, as distribution depends on charitable donations. • The Vision of Children Foundation is not responsible for repairs or replacements if the device becomes damaged or malfunctions. • The application must be fully completed to be considered. • Any medical or personal details are shared voluntarily and will only be used for evaluating eligibility. • VOC may contact my child’s physician with my explicit consent for any further medical verification if necessary.

Yes I agree

Name of Parent/Guardian: *

By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.

First Name

Last Name

Date *

MM

DD

YYYY