City & Country Serving (required)
Mission Dates: (required)
Glasses Delivery Date (required)
Do you want sunglasses in your glasses pack?
Handheld autorefractor loaner requested*
U.S. Delivery Street Address: (required)
Is the shipping address a residential one?
If this is shipping to a business address, what is the name of the business?
Name of Your Organization
Are you a non-profit?
Type of Mission
How did you hear about this program?
Special Requests or Questions
I agree to return the Mission Support Stories document* and 3-5 photos taken from the mission trip after I return home. (*Please note: The document will be emailed to you along with the confirmation of your request.)
The first 300 readers and 100 sunglasses will be provided at no cost.
* You will receive your handheld autorefractor 1-2 weeks before you depart for your mission trip and must send the handheld autorefractor back to National Vision the week you return. This is to ensure that NVI is able to maximize accommodation of requests.
In return for the items NVI donates/loans to your trip, we request that you share stories, photos and data (# of patients seen, # of glasses distributed, etc.) with us upon your return.
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