Mission Support Request

About You

Required fields are marked with an asterisk (*).

Your Name * Email Address * City & Country Serving *

Mission Dates From * To * How many people do you expect will receive a vision screening? * Glasses Delivery Date *

All orders need a minimum of two weeks to process.

Request Sunglasses * Yes No

Request Handheld Autorefractor Loaner * Yes No

US Delivery Address Address * Address Line 2 City * State * Zip Code *

Is the shipping address a residential one? Yes No

If this is shipping to a business address, what is the name of the business? *

Phone Primary Phone * Cell Phone

Organization Name of Organization *

Are you a non-profit? * Yes No

Type of mission * This is a VOSH Mission This is a SVOSH Mission Other

Other

How did you hear about this program? Special Requests or Questions

By submitting this form, I agree to return the Mission Support Stories document* and 3-5 photos taken from the mission trip after I return home. (*Please note: The document will be emailed to you along with the confirmation of your request.)

Up to the first 300 readers and 100 sunglasses will be provided at no cost.

You will receive your handheld autorefractor 1-2 weeks before you depart for your mission trip and must send the handheld autorefractor back to National Vision the week you return. This is to ensure that National Vision is able to maximize accommodation of requests. National Vision will cover the cost to send you the handheld autorefractor. It is your responsibility to cover the cost to return the autorefractor back to National Vision.

In return for the items National Vision donates/loans to your trip, we request that you share stories, photos and data (# of patients seen, # of glasses distributed, etc.) with us upon your return.