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Play Hard. Don't Blink. Prescription Goggle Program Application
Required Required Question(s)
Required 1.

What is the total number of people in your household living with you, including yourself?
 

  • 50 characters left.
Required 2.

What was your household’s approximate gross income (before taxes and deductions), including income from other sources such as alimony and child support? Please mark it monthly or yearly.
 

  • 50 characters left.
Required 3.

Please enter the names and AGES of the children you wish to apply for. Enter one child per line.
 

  • 350 characters left.
Required 4.

Please enter contact information for a parent of the child(ren) listed above. ANY DAY TIME phone number instead of a work number is needed.
First Name:
Last Name:
Work Phone:
Email Address:
emailaddress@xyz.com
Address 1:
Address 2:
City:
State/Province
(US/Canada):
Postal Code:

PLEASE ALLOW 2 WEEKS FOR APPLICATION PROCESSING.