Become a Blood Donor | Lions Club of Colombo LEADS

Child First Name *

Child Last Name *

Date of Birth *

Age

Gender *

Grade / Year *

School Name *

School Area *

District *

Parent / Guardian Name *

Mobile / WhatsApp *

City / Area *

Relationship to Child *

Email

Has the child had an eye examination previously? *

Does the child currently wear spectacles? *

Does the child have difficulty seeing clearly? *

When was the child's last eye examination?

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

Please provide details *

What vision difficulty 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 *

Letter from School *

Upload School Letter *

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

School Letter Templates

Schools may use either template depending on whether the application is for an individual student or multiple students.

Download – Individual Student Letter Download – Multiple Student Letter

FREE SPECTACLES FOR SCHOOL CHILDREN

Registration Form