Practice Pledge USA Home » World Sight Day Challenge » Practice Pledge USA Practice Registration Form - USA - World Sight Day Challenge 2023 YES, I WOULD LIKE TO REGISTER FOR THE 2023 CHALLENGE!SUGGESTIONS FOR PRACTICE FUNDRAISING: Donating $2 or more for every pair of glasses sold during September and October Donation based on the number of exams given during September and October Match patient donations Fundraising activity (i.e., raffle, silent auction, candy jar guessing contest, etc) I would like to pledge practice participation at the following level: $1500+ $1,000 - $1,499 $500 - $999 $250 - $499 Other pledge amount: Send kit Please send me a free World Sight Day Challenge kit for a minimum pledge of $100, that includes a poster, counter card, brochures, social assets, stickers and 'How-to Guide' GENERAL DETAILSPractice Name* Contact Person's Name (Your practice's 'Champion')* Contact Person's Name Title (ie: Dr., Mr., Mrs., Ms., etc) Contact Person's Job Title* Contact Person's Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone* Fax Number If you have additional people (Champions) who would like to receive our communications regarding your practice's participation in the World Sight Day Challenge, please enter their names and email addresses here:
