Share Your Story

Fill out my online form.

Vision Screening Program - Share Your Story

If you want to share how the Vision Screening Program has impacted your child or student's life, you can fill out the form below.

The undersigned has entered into this agreement and holds true to this account to the best of their knowledge in order to assist scientific, treatment, educational, public relations, or charitable goals and hereby waives any right to compensation for such uses by reason of the foregoing authorizations. The undersigned and his/her successors or assigns hereby hold LLUH, its affiliates, and their successors, and assigns harmless from and against any claim for injury or compensation resulting from the activities authorized by this agreement.

By submitting this agreement, or by submitting this agreement on behalf of a minor, the undersigned gives LLUH and its affiliates the right to use name, name of minor, media, and/or quotes and may use and permit other persons to use name, images, and/or quotes in a manner deemed appropriate. The undersigned agrees dissemination to employees or volunteers of LLUH or its affiliates, physicians, health professionals, public relations, and charitable purposes and that such dissemination may be accomplished in any manner.

The term “media” is used in the foregoing agreement shall mean motion picture or still photography in any format or any medium including video tape or disc, digital recording or any other means of recording and reproducing images.

By submitting, you authorize and consent to publishing any media material taken from the event.