EYE SCREENING CONFIRMATION FORM

DIABETIC RETINOPATHY/MACULAR DEGENERATION

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Lions Club________________________________________________________District________________________

President_______________________________________________________________________________________

Home Phone #__________________________________Business Phone#____________________________________

                     BOTH A DAYTIME AND NIGHTTIME PHONE NUMBER IS NEEDED

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____Yes, we will be able to have the screening on ___________________________________

               REMEMBER:                                       (Date)

     A DARK ROOM IS NEEDED                       ____________________________________

                                                                            (Time)

Exact Location of Screening Site:

Name of Facility/Location___________________________________________________________________________

Address___________________________________________________City____________________Zip____________

Add'l Information______________________________________________________________________________

Phone # (nearest to screening site)_____________________________________________________________________

(This number will be used to contact our staff member only if necessary)

                                    Include any directions that might be needed on the back of the form

Lion in Charge of the Screening:

Name_________________________________________________Title______________________________________

Address___________________________________________________City____________________Zip____________

Home Phone #__________________________________Business Phone#____________________________________

Lion in Charge of Publicity:

Name_________________________________________________Title______________________________________

Address___________________________________________________City____________________Zip____________

Home Phone #__________________________________Business Phone#____________________________________

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______No, we are unable to sponsor the screening as indicated.

Reason__________________________________________________________________________________________

Signed__________________________________________________Title_____________________________________

PLEASE RETURN THE ENTIRE FORM