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-Kindergarden
 # of Classes # of Students
Kindergarden
 # 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