Outreach Request

Please fill out the following form below providing as many specifics as possible.

SECTION A: COMPANY/ ORGANIZATION DETAILS

Company/Organization Name

Main Contact Person

Company/Organization Address

Phone

Email

SECTION B: EVENT SPECIFICS

Event Description - Please describe your event

Location / Address of Event

Date of event

Number of persons expected

Age group of attendees

0 - 12

13 - 17

18 - 40

40 - 60

60+

Will there be other eye care companies present?

Yes

No

Comapny/Organizatin will provide

Electrical Connection

Tables

Chairs

Meals

Water

Time of event

Peak Times

Services Requested

Vision Screening

Diabetic Eye Screening

Information Booth

Presenter/Speaker

Please state which other eye care companies will be present, if any

Supporting Documents/flyer (If Any)

Upload

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

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