Scheigert Scholarship Program
Eye Report Form
As part of the Fred Scheigert Scholarship Program and Magnification and Award application process which is administered by CCLVI, qualified applicants need their doctor to complete this form. This form is only to be completed by a licensed Opthalmologist or Optometrist.
This secure form requires a Gmail account. If you do not have a Gmail account, the next screen provide you the option to create a free one. This secure system allows you to save your work, and continue it later if needed. It also allows us to confirm your submission.
Thank you in advance for your assistance.