World Sight Day Challenge Registration Form

To register for Optometry Giving Sight's World Sight Day Challenge simply fill out and submit the form below. Once registered we will send you your World Sight Day Challenge Practice Kit. This will include materials to help you promote the Challenge in your practice and in your community.

Yes I would like to participate in the World Sight Day Challenge

I am:


	A Practice that wants to donate our eye exam fees on World Sight Day, and/or

	Optometrist who wants to sign up for a regular monthly or annual donation, or

	Staff who would like to sign up for a regular donation of at least $5 per mth

	Student who would like to sign up for a regular donation of at least $5 per mth

Other (please specify)

Please contact me / my practice to make arrangements to implement the Challenge in our practice. The best time to contact me / my practice manager is:
(please include name of practice manager where appropriate)

Time:

Practice manager:

First Name : (required)

Last Name : (required)

Comapny Name: (if applicable)

Position:

Address: (required)

City: (required)

Postcode / Zipcode : (required)

Country: (required)

Phone: (required)

Email Address: (required)

Comments: