Testing Form Shortcode KVFL Glasses Replacement Request Form This is the form that will automatically update the spreadsheet information. This was created Oct 2025 By Sam Crowe @ The Creative Crowe. Glasses Replacement Request FormKVFL offers FREE replacement glasses to all students in the St. Louis region with a current prescription, regardless of the provider. Please note that vision prescriptions expire after one year. Did your child receive an eye exam from KVFL in the past year? Yes - My child was seen on the KVFL Mobile Vision Clinic at their school.First Choice Yes - My child attended a Summer Clinic with KVFL. No - My child received an eye exam from another provider. For reporting purposes, can you please tell us if your child's glasses were lost or broken? Glasses are lost Glasses are broken Unknown What school does your child currently attend? *(Required)Please share the Building Name AND the School District to expedite your request.If different, what school did your child attend last school year?Please share the School District and the Building Name.Student Name *(Required) First Last Student Date of Birth *(Required) MM slash DD slash YYYY Parent Name *(Required) First Last Parent Email *(Required) Enter Email Confirm Email Parent Phone Number *(Required)Please provide a detailed description of your child's previous frames:Please include, Brand, Model #, Measurements, Color, etc.Does your child have a current prescription from a different provider? Yes No If your child's most recent eye exam was not with KVFL, please select YES and upload a copy of your child's prescription below. Prescriptions must be within one year to be valid. Please make sure your child's prescription includes a PD measurement.File UploadMax. file size: 2 GB. Please upload a copy of your child's current prescription here for our records.Comments or Questions for KVFL Staff: *(Required) Please provide any other details that would help us complete your order. Δ
