OTGi Application Form 10-16-years old

OTGi Application Form 10-16-years old

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1. Full Name of Child *

First Name	*
Surname	*

2. Full Name of Parent/Guardian *

First Name	*
Surname	*

4. Child's Date of Birth *

	DD/MM/YYYY

5. Child's Age (must be 8-18 years old to register) *

6. Child's Sex *

Male
Female

7. Your Address *

8. Contact Number(s) *

Main	*
Home
Alternative

9. Your Email Address *

11. What is your child's spectacle prescription? (from the last opticians eye test, leave blank if unsure) NOTE: If using a smart phone, turn screen landscape

	Sphere	Cyl	Axis	Near Add
Right Eye	Right Eye Sphere	Right Eye Cyl	Right Eye Axis	Right Eye Near Add
Left Eye	Left Eye Sphere	Left Eye Cyl	Left Eye Axis	Left Eye Near Add

12. Please attach a photo of the spectacle prescription (from the last opticians eye test, leave blank if not possible)

File: {{filename}}delete

Choose File

13. Does your child wear glasses or contact lenses at present? *

No
Yes, glasses only
Yes, contact lenses and glasses