Little Bear Gives iPad Fundraiser Project Application About YouEnter information about you, the parent or guardian.Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email* Phone*About the ChildEnter information about the child who will be considered for the iPad fundraising project.Name* First Last Date of birth* Date Format: MM slash DD slash YYYY Has your child been diagnosed with CVI?*YesNoWhat type of healthcare provider completed the diagnosis?Your child's story:*Please tell us a little about your child’s story. This should include how your child came to have CVI and possibly any additional diagnoses.Your child's journey with CVI:*Please tell us about your journey with CVI. How did you first learn your child had CVI? Has your child been officially diagnosed? Has your child been misdiagnosed? What challenges and successes have you encountered in getting a diagnosis and proper support? Have you seen improvements in your child’s vision?Your child today:*Please tell us who your child is today. What does s/he like or dislike? What are his/her strengths? What current challenges and successes is s/he facing?CVI CharacteristicsWhich of the following CVI characteristics does your child display?Preference for a specific color*You may have noticed that your child seems to prefer looking at a certain color. Bright red and yellow are often favorite colors, but some children prefer other bright colors such as blue, green, or pink.YesNoNeed or preference for movement*Many children with CVI require movement in order to see an object. For example, it may be easier for them to look at a pinwheel or a swaying balloon.YesNoDifficulty with visual complexity*Children with CVI need simplicity. They may prefer simple one or two colored objects presented against a black background.YesNoLight-gazing and nonpurposeful gazing*Often, children with CVI will stare at light. They may be seen gazing out the window or up at a ceiling light. They may also appear as if looking at things that are not there, or looking at things without intent.YesNoVisual field preference(s)*Most children with CVI will prefer to look at objects in a particular direction. For example, they may see an object better when it is presented in their periphery, or may turn their head to see an object.YesNoDistance vision impaired*Some children with CVI have trouble seeing far away. This is related to the preference for visual simplicity. Objects far away may be lost in visual clutter.YesNoVisual blink reflex is absent or impaired*When an object comes too close to the eyes, or touches the bridge of the nose, many CVI children have an absent or delayed protective blink response.YesNoPreference for familiar objects*Because it is difficult for CVI children to process the information that the eyes see, they often prefer familiar objects that the brain easily recognizes and has processed before.YesNoImpaired visually guided reach*The ability to look at an object while reaching for it is impaired. Often CVI children will look away from the object and then reach for it.YesNoAny other characteristics you’ve noticed?Please describe them here:Terms and SignatureTerms and Conditions:*The information submitted in this form may be used for the Little Bear Gives iPad Fundraiser Project for promotion, marketing and content purposes. Submitting the form in no way guarantees participation in the Little Bear Gives iPad Fundraiser Project. Submitting the form in no way guarantees receiving an iPad. If selected, I agree to furnish 15-25 pictures of my child to be used on the project page and in marketing the project page. Yes, I agree with the terms and conditions. Electronic Signature*Please sign by typing your name below: Δ