TUDENT _ ADDRESS TELEPHON SCHOOL PARENT/GMIRITAll BIRTHDATE City SEX /:=7 State ETHNICITY Zip Code GRADE 3 TEACHER Reason for referral: Visual Acuity without glasses: Visual Acuity with present glasses: Visual Acuity with prescription recommended: Title Form f 878-1273 MIS-12125 (08-78) EFTA