POULSON FAMILY SCHOLARSHIP APPLICATION, Part Two
VI. Certification of Visual Status
To be completed by an ophthalmologist, optometrist, or agency serving the blind.
This certifies that ________________________________________,
in his/her best eye with best correction, has a visual acuity of ________________________________________, a visual field of ____________________ degrees, or a functional visual impairment (please describe) ________________________________________
________________________________________
________________________________________
________________________________________
________________________________________
Name: ______________________________
Title: ______________________________
Address: ___________________________________
___________________________________
___________________________________
Phone: ______________________________
Date: ______________________________
Signature: ______________________________