Individuals/groups interested in engaging with ASPECT can complete this application. Please email Julie Grutzmacher, Director of National Collaboration and Engagement at Prevent Blindness with questions at: [email protected] Name* Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Middle Last Suffix Email* Preferred mailing address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Telephone number*Ethnicity/Race* American Indian or Alaskan Native Asian Black or African American Hispanic, Latino, or Spanish origin Native Hawaiian or other Pacific Islander White Multi-racial/Other (Please check all that apply)Please indicate your prospective role in the program.* Patient (individual with an eye disease or condition, vision impairment or blindness) Ally/Caregiver Representative from nonprofit or industry partner Clinician/Researcher (Please check all that apply)If you are a patient, what is your vision diagnosis?If you are a parent, guardian, or caregiver, what is your child’s or loved one’s vision diagnosis? Give Us Your Feedback Was this page helpful? Name First Last Email Please give us any feedback you have about this page.What was helpful or what was missing?EmailThis field is for validation purposes and should be left unchanged.
