Complete the following entry to apply for a free eye exam and free pair of glasses from the SPECS Program from Dr. Jeff Long's Children & Family Eye Care. You may submit for yourself, or someone else that truly needs this eye care gift.

The SPECS Program: Servants Providing Eye Care Services is a program dedicated to improving the lives of others around the world. The program is committed to creating an impact to communities locally and abroad.

The mission is simple...Free eye exams and glasses provided to those in need to allow as many people as possible the opportunity to enjoy the gift of sight.

K95.5 and Dr. Long will award one free eye exam and pair of glasses (if necessary) each weekday for the duration of this program.

ALL FIELDS REQUIRED EXCEPT WHERE INDICATED (OPTIONAL)