Request Eyewear Donations

Please allow up to 10 business days for our team to review your request and respond with an update.

All fields are required unless noted.

Your Information

Name

Title

Phone

Organization/Practice Name

Website

Street Address within the U.S.

City

State

Zip Code

Tax ID/Employer Identification Number (EIN)

Is your organization recognized as a 501(c)(3) charitable organization?

Yes No Not sure

Event Details

Who will prescribe and/or dispense the eyewear requested?

Optometrist Ophthalmologist Other

If other, please specify

Describe how the eyewear requested will be used on your mission trip or during outreach.

In what country/countries will the requested eyewear be distributed?

When do you need the requested eyewear to be delivered?

When will the requested eyewear be distributed?

Eyewear Needs

What type of eyewear are you requesting for donation? Select all that apply.

New Optical Frames: Must be provided at no cost to the patient. New Sunglasses: Must be used for eye health-related outreach and provided at no cost to the patient.

You indicated your organization would like to receive New Optical Frames. Please select the type and quantity.

Enter Quantity of Men's

Enter Quantity of Women's

Enter Quantity of Children's

Special Requests

You indicated your organization would like to receive Sunglasses. Please select the type and quantity. Children’s sunglasses are not available.

Enter Quantity of Men's

Enter Quantity of Women's

Submit