Register Your Child

Child with glasses

In order to register your amblyopic child and receive free material as list below, your child must have been diagnosed with amblyopia by an eye doctor. Please talk with your child's eye doctor before registering and, ideally, obtain a registration form from your eye doctor. Registration is open to any amblyopic child up to 18 years of age who lives in the State of Ohio.

What you will receive for free once you register your amblyopic child:

1. Brochures

	Amblyopia (lazy eye)
	Strabismus (misaligned eyes)
	First Aid for Eye Emergencies
	Don’t Play Games with Your Eyes
	Play it Safe
	Your Child’s Sight
	Signs of Possible Eye Trouble in Children
	Common Eye Problems

All literature has been reviewed and approved by the Ohio Amblyope Registry Board. The board includes two ophthalmologists, two optometrists, CEO of the Ohio Optometric Association, Executive Director of the Ohio Ophthalmological Society, a representative from the Ohio Department of Health and the Ohio Amblyope Registry Board Executive Director.

2. If your child is being patched for amblyopia, s/he will receive 6 free boxes of eye patches, a $30.00 value!

3. If your child is being patched for amblyopia, s/he will also receive two (2) free cloth patches that cover one side of glasses.

3. If your child is being patched for amblyopia and if s/he is between the ages of 4 and 9 years, you will receive the Eye Patch Club packet! The Eye Patch Club packet includes the following:

	Newsletter about tips and techniques for promoting compliance and professional advice from optometrists, ophthalmologists and orthoptists;
	A classroom guide for teachers and fellow students about lazy eye;
	an Eye Patch calendar with stickers;
	A refrigerator magnet;
	A pen pal form in the event that the older child wants to join a pen pal club of other amblyopic children.

The Eye Patch Club packets are restricted to children between the age of 4 and 9 years who are currently undergoing patching therapy. Want to learn more about the Eye Patch Club packet from Prevent Blindness America (PBA)? Click-on the link below and you will be taken to the PBA web site that describes the Eye Patch Club packet information. Don't forget to come back and be sure to include this site in your Favorites!

http://www.preventblindness.org/children/EyePatchClub.html

All free materials are paid for by the Save Our Sight Fund for Children, which receives voluntary donations via the check-off box on Ohio license plate renewal forms. Support the Save Our Sight Fund for Children the next time you renew your license plate.

Amblyopic Child Registration Form

The following information will remain strictly confidential. You and your child's name and address (and any other personal information) will only be used to send information to you. We will not release your personal information to anyone for any reason. All information is removed from the internet and placed on a secured computer that does not have internet capability. Any reports we produce will be summary data only with no names, addresses or personal information used, as mandated by the Ohio Department of Health.

Child's Name: First

Last

Parent's Name: First

Last

E-mail Address:

Mailing Address: Street

City

County

State

Zip

Phone

Child's date of birth (mm/dd/yyyy)

Child's date of diagnosis (month/year)

Child's Race

Child's Social Security Number (optional):

My child has insurance coverage.

My child's Eye Doctor is:

Doctor's Phone

Doctor's Address

Type of Doctor

Important: Is your child undergoing patching therapy?

(i.e., Child wears an eye patch over his/her good eye?)

Check all the apply:

I would like to receive written brochures about amblyopia, eye safety, strabismus, etc. (Ohio residents only)

I would like to receive the following (Ohio residents only):

Letter reminders of the importance of maintaining my child's eye doctor appointments as well as newsletters and other written information about amblyopia as it becomes available.

Email reminders (be sure to include your e-mail address above) of the importance of maintaining my child's eye doctor appointments and other internet related information about amblyopia as it becomes available.

1. How was your child�s amblyopia discovered?
By eye doctor on regular exam.
Pediatrician/family doctor suggested an eye exam, which lead to the diagnosis of amblyopia.
Child failed an eye screening test (at school, daycare, etc.,) and it was recommended that child see an eye doctor who diagnosed the amblyopia.
Nurse, teacher, other non-doctor professional suggested that I take my child in for an eye exam and amblyopia was diagnosed.
Other: please explain how the child was found to have amblyopia:

2. How did you find-out about the Ohio Amblyope Registry?

From my Eye Doctor or Eye Doctor's office.

From searching the Internet.

Other; please list:

3. How can the Ohio Amblyope Registry help you, as a parent of a child with amblyopia? Please list and help us improve:

If financial assistance is needed, please speak with your eye care provider about any assistance that might be available. You can also contact your local Health Department about filling-out a Combined Programs Application (includes Medicaid and BCMH) for financial assistance to cover your child's eye care needs.

Thank You