Please fill out this form to the best of your knowledge. The information below helps us to properly evaluate and plan for training and equipment needs. Contact Information * Email Address: * Confirm Email Address: * First and Last Name: * Address: Address 2: * City: * State: * Zip Code: * Phone: * Preferred Contact Method: —Please choose an option—EmailPhoneMail * Preferred Contact Time: —Please choose an option—Morning (before noon)DaytimeEvening (after 5 pm) EagleEye Users Information Intended User First and Last Name: Users Birth Date: Primary Diagnosis: Was condition present at birth: YesNo If yes, please provide an explanation: Is purposeful head control present: YesNo Is purposeful eye control present: YesNo In what setting will the EagleEyes technology be used: —Please choose an option—ClassroomHomeCenterHospitalOther (please describe) If you selected other, please describe the environment setting: Relationship to the EagleEyes user? Is there a possibility of an LCD projector or a large visual screen?: YesNo First and last name of the person responsible to provide technical support to the EagleEyes program: Δ
