Full Name

First Name

Last Name

Phone Number

Country

(###)

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Full Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthdate *

MM

DD

YYYY

Parent / Guardian Full Name

First Name

Last Name

Parent / Guardian Phone Number:

Country

(###)

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Parental/Guardian Consent (If Candidate is Under 18)

As the legal guardian of the above-named candidate, I hereby provide my consent for my child to participate in the Vision Heroes Program. I further give permission for The Vision of Children Foundation to use my child’s name, likeness, and story in any media materials (e.g., promotional videos, social media, press releases) related to the program. Data Privacy and Protection By submitting this application, I understand that all personal information provided will be securely stored and used solely for the purpose of evaluating candidates for the Vision Heroes Program. This information will not be shared with third parties without prior consent, in accordance with the California Consumer Privacy Act (CCPA) and, where applicable, the General Data Protection Regulation (GDPR).

Yes

Parent/Guardian Full Name: *

By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.

First Name

Last Name

Date *

MM

DD

YYYY

Health Information Consent *

I acknowledge that any medical information provided (e.g., vision diagnosis) will remain confidential and will be used only for the purpose of evaluating eligibility for the Vision Heroes Program.

Yes

Signature of Candidate (or Parent/Guardian if under 18): *

By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.

First Name

Last Name

Date *

MM

DD

YYYY