Prescription goggles
parent application form

We’ve made it easy. So you can be more super.

Welcome to the Superspecs free prescription sports goggle program. This program is sponsored by Save Our Site, Ohio Prevent Blindness, and the Ohio Ophthalmological Society with a grant from the Ohio Department of Health for children at or below 300% of the Federal Poverty Guidelines. For 2018–2019, the maximum gross annual income for a family of four is $75,300.

Parents, before completing this online application, please be sure to read the instructions in full, below.


Please complete the following application carefully. When you get to the end, click “submit.” If you are approved, you will immediately receive an email stating so. Since this email is computer-generated, please check your spam and junk mail folders.

After your approval, choose a participating office from the link below. You do not need to take anything with you to your appointment besides your child and their prescription. The participating office will order the prescription sports goggles, and they will be delivered within 6 weeks to your home address. Please be patient, as we don’t monitor the day-to- day status of the orders.

In special circumstances, you may gather all of the information and complete the order yourself. We don’t recommend this, as it’s a highly technical process. Unfortunately, we do not provide exchanges or returns for incorrect orders, and you must wait 12 months before applying again.

Questions?
Please email us at oos@ohioeye.org. No phone calls, please.

Click here for a list of participating offices.


Income qualifications

Total gross annual household income cannot exceed this amount:

Household/
Family Size
Household
Income
2 $49,380
3 $62,340
4 $75,300
5 $88,260
6 $101,220
7 $114,180
8 $127,140
9 $140,100
10 $153,060

Child's Information

Please enter the name and age for the child you wish to apply for. Each child will need their own application form submitted.

Your child must be between the age of 4-18 in order to qualify.

Please do not include any symbols and round to nearest whole dollar. (ex: 30000)

Parent/Guardian Contact Information

Goggles will be mailed directly to your residence within 6 weeks. No rush orders.

Only Ohio residents are eligible at this time.