Jones Family Redirecting the Light Fund In Honor of Joan Foley

Order form for EnChroma Color Correction Glasses

Parent/Guardian Contact Information

Provide the following contact information for the person completing the application.

First Name

Last Name

Personal Email

Preferred Phone

Home Phone

Mobile Phone

Street Address

State

City

Zip Code

Student Information

First Name

Last Name

Student's Current Grade

School District

EnChroma Order Information

Type of Glasses Ordering

Upload a file or photo of the student's lens prescription

Type of Color blindness

Lens/Frame Selection

For Indoor glasses select an option that includes the word "Indoor." For Outdoor glasses select an option that includes the word "Sun."

I certify that the submitted information and the statements contained hearin or attached hereto are true and accurate to the best of my knowledge. I further authorize the Southwest Initiative Foundation to verify the submitted information by contacting any individual or organization deemed to have knowledge of the proposed project. Southwest Initiative Foundation will share the personal information provided herein with EnChroma. As parent or legal guardian, I authorize my child, as recognized within this application, to participate as a recipient of this vision correction product.

I agree

Southwest Initiative Foundation and EnChroma has my permission to use my or my child’s photograph publicly. I understand that the images may be used in print publications, online publications, presentations, websites, and social media. Images may be edited for style and design purposes. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.

I agree

Primary Contact-Accounting

Southwest Initiative Foundation is a nonprofit community foundation connecting people, investing in ideas and building communities to create a southwest Minnesota where all people thrive. Learn more at swifoundation.org.

Southwest Initiative Foundation | 15 3rd Ave NW Hutchinson, MN 55350 | (320) 587-4848 | info@swifoundation.org
Copyright © 2020 Southwest Initiative Foundation, an equal opportunity provider and employer.