This form can be completed and sent in at anytime. If the student is approved for a clinic spot, they will be placed on the waiting list for the next clinic closest to their home region.

Please refer to the CLVP website http://clvp-bc.sd23.bc.ca for upcoming clinic locations and dates.

**Please note ALL FIELDS need to be completed for referral to be considered**

*Preschoolers must have receiving vision teacher for kindergarten attend the clinic with them.

Please attach a copy of the student's most recent eye report to complete the referral process.