Free Spectacles | Lions Club of Colombo LEADS

Child's First Name *

Child's Last Name *

Date of Birth *

Age

Gender *

Year *

School Name *

School Area *

District *

Parent / Guardian Name *

Mobile / WhatsApp Number *

Email

City / Area *

Relationship to Child *

Has the child had an eye examination previously? *

When was the child's last eye examination?

Does the child currently wear spectacles? *

Does the child have difficulty seeing clearly? *

Does the child have any known eye condition or vision-related problem? *

What vision difficulties does the child experience? *

Please select all that apply.

Difficulty seeing the blackboard at school Difficulty reading books or schoolwork Difficulty seeing things from a distance Difficulty seeing things up close Blurred or unclear vision Frequent headaches or eye strain Difficulty seeing at night No specific difficulty, but an eye examination is recommended Other

Please specify the other vision difficulty *

School Letter *

Upload School Letter *

Accepted file formats: PDF, JPG, JPEG and PNG. Maximum file size: 10 MB.

School Letter Templates

Schools may use either template depending on whether the letter is for an individual student or multiple students. The letter should be prepared on the school's official letterhead and signed by the Principal or an authorized officer.

Download – Individual Student Letter (.docx) Download – Individual Student Letter (PDF) Download – Multiple Student Letter (.docx) Download – Multiple Student Letter (PDF)

FREE SPECTACLES FOR SCHOOL CHILDREN

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