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 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.