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REALEYES
Realeyes Program Overview
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Realeyes Request Form
School Name:
Address:
City:
Zip:
County:
School District:
Primary Contact
First Name:
Last Name:
Position:
Phone:
Email:
Each Realeyes presentation involves a movie component.
Be prepared to show a DVD, VHS tape, or stream the videos through YouTube.
Select all grades that request presentations.
Provide the # of classes in each of those grades AND the
TOTAL
# of students in each of those grades.
Sammy Safe-Eyes
(30 minutes)
Pre-Kindergarten
# of Classes
# of Students
Kindergarten
# of Classes
# of Students
The Adventures of Rhet & Tina
(45 minutes)
1st Grade
# of Classes
# of Students
2nd Grade
# of Classes
# of Students
The Case of Vinny Vision
(45 minutes)
3rd Grade
# of Classes
# of Students
4th Grade
# of Classes
# of Students
5th Grade
# of Classes
# of Students
What's Your EYE-Q?
(45 minutes)
6th Grade
# of Classes
# of Students
7th Grade
# of Classes
# of Students
8th Grade
# of Classes
# of Students
Specific instructions
For scheduling purposes, Please complete the information below.
Start time of school day:
End time of school day:
Best month or time of year:
Best time of the day:
Best day of the week:
Is there an optometrist with whom you want to schedule?
Does your school hold a health fair in which we can Participate?
If YES, What is the date?
Fair Coordinator Name:
Coordinator Email:
- denotes required fields
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