CCLVI Scholarships

The Council of Citizens with Low Vision International

Scholarship Applicant's Eye Report Form

Name of Applicant:

Address:

City:                                         State:         Zip Code:

Telephone: (       )          -

Date of Birth:         /         /         Gender: M   F

Date of Examination:         /         /

Visual acuity (with best possible correction):
Near OD             Distant OD             Field restriction (if any):
Near OS             Distant OS

Cause of vision impairment:

Medical History or other pertinent information:



Doctor’s Name:

Doctor's Address:

City:                                         State:         Zip Code:

Telephone: (       )          -

Signature (Dr.)                                                Date:         /        /

Thank you for your assistance. The Council of Citizens with Low Vision International is an affiliate of the American Council of the Blind, Washington, DC.