Please fill out this form to request your free replacement cane from Eye Learn. We do not deliver canes at this time. We will notify you via phone or email when your cane is ready for pickup, so please ensure you provide a valid phone number or email address. You must bring your old cane to us when you pick up your new cane. The address for our facilities is provided below, along with additional information. You may only request one cane, and you must be blind or filling this form out on behalf of a blind person to qualify.

If you are filling this form out on behalf of another person, please put in their information and not your own.