Share Sight Initiative Form

SHARE SIGHT INITIATIVE FORM

Nominee's information:

* Indicates required field

Name *

First

Last

DOB: mm/dd/yyyy *

Select one *

Male Female Prefer not to answer

Phone Number *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

If and when selected for Share Sight, please select the location you'd like to be seen at:

Please select one *

Portland Location Beaverton Location No preference

Please select your usual availability for each day:

Mondays *

Tuesdays *

Wednesday *

Thursdays *

Fridays *

Saturdays *

Availability Notes *

To be considered for Spectacle's Share Sight Initiative, please answer the questions below honestly and to the best of your ability.

Do you currently have vision insurance? (Y/N) *

How long have you been wearing glasses? *

What is the most rewarding thing you've done in life or in your career? *

In detail, how will our Share Sight Initiative improve or impact your quality of life? Do you have anyone you would like to nominate? Why? *

Submit