If your family income falls at or below the following guidelines, then your child qualifies to receive up to 15 additional boxes of patches!

*For families with more than 8 persons, add $6,960 for each additional person.

Step 1: Fill out the application form.

Step 2: Attach proof of income document (see application form for acceptable documents).

Step 3: Mail application form and proof of income to:

Ohio Amblyope Registry

Nationwide Children’s Hospital

700 Children’s Drive

Columbus, OH 43205

Patches Form (Click Here to download)       

Print this page or download by clicking above link.  With a pen, fill-out all information completely. Send application by mail to:

Ohio Amblyope Registry, Nationwide Children's Hospital, 700 Children’s Drive, Columbus, OH 43205

Patient Name: _________________________________________

Parent Name(s): _______________________________________

Patient Mailing Address: ____________________________________________________

_________________________________________________________________________

Phone Number: __________-__________-__________

Patient’s birth date (month/day/year): _________/_________/________

Patient Social Security Number (required by ODH): ________-________-__________

Is the patient a resident of Ohio? ________Yes ________No

What county of Ohio does the patient live in?: __________________________________

Is the patient a citizen of the USA? ________Yes ________No

Annual Household income: $______________

Number of family members living in household: ________________

With the application form, submit one of the following:

1. Copy of work pay stub from each working adult in household.
2. Copy of W2 tax form from each working adult in household.
3. Other form or information about your household annual salary.

Limitations: Limited to Ohio residents only. Form must be completely filled-out to be considered. Patches are restricted to those families with a household income of less than two (2) times the federal poverty guidelines for family size. Patients are limited to a total of 15 large boxes of patches in lots of 3 boxes at a time. You can call the toll-free number (1-877-808-2422) or visit the web site for the Ohio Amblyope Registry (OhioAmblyopeRegistry.com) to request additional patches. Please allow 1 week delivery time for your patches. All information is strictly confidential and for program use only. Funded by The Ohio Department of Health, Bureau of Child and Family Health Services, Save Our Sight Program.

Parent or Guardian Sign Here:  ______________________________________

Date:  ___________________________