Friendly Lions Club



FRIENDLY LIONS CLUBAPPLICATION FOR EYE EXAM/GLASSESCOMPLETE AND RETURN IN THE ENVELOPE PROVIDEDApplicant’s Name__________________________________ Age___Circle one (Married, single, widow, widower, divorced)Is request for Applicant or Minor Child in Applicant’s Care? (self, child)If for child, please list child’s age___ Applicant’s Address_____________________________________________________________________City/State____________________________________Zip Code__________________________________Telephone___________________________Years at this address_________________________________Place of employment____________________________________________________________________Address______________________________________________________________________________City/State_________________________________________________Zip Code_____________________Telephone_________________________________________Years of employment__________________Household Income (wages, child support, Social Security, unemployment, ect) $____________________Number of Dependents living in residence______Name__________________________________________________________________Age___________Name__________________________________________________________________Age___________Name__________________________________________________________________Age___________Name__________________________________________________________________Age___________Household expenses: Rent (yes/no) ___________/month Own Home (yes/no)Utilities (gas, electric, water/sewer, phone, TV cable/satellite, ect) per month $_____________________Does Applicant/Applicant’s Child have a West Virginia Medicaid Medical Card? (yes/no)Does Applicant/Applicant’s Child have Medicare? (yes/no)Does Applicant/ Applicant’s Child have ANY type of insurance that covers vision? (yes/no)Has Applicant/Applicant’s Child ever worn prescription eye glasses? (yes/no) How many year?________Date of last eye exam__________________Name of Eye Doctor_____________________________________________________________________Doctor’s address_______________________________________________________________________City/State____________________________________________Zip Code__________________________Telephone_________________________________Why do you need Lions Club assistance?Would you like more information on possible membership to the Lions Club? (yes/no)I hereby certify that all the information enclosed in application is true and complete to the best of my knowledge. I also certify that any false statements made on this application for Lions Club assistance may void this application. I also certify that the sight chair of the Friendly Lions Club may contact me if he/she has any questions. The Lions Club will accept/reject the application based on the information provided by the applicant.X_______________________________________________________Date_________________________Please note the following:All approved applications are referred to Dr Robert Christen for your eye exam/glasses. We will contact you to schedule your appointment with Dr Christen at YOUR convenience.Unless medically necessary or for some unforeseen emergency, the Friendly Lions Club will only pay for eye exam/glasses every two years. IF you have a West Virginia Medicaid Medical Card, Medicaid will pay for the eye exam but NOT glasses. Please make sure you indicate on the application IF you have a West Virginia Medicaid Medical Card.Please return the completed application in the envelope provided.If you have any specific questions, please contact Lion Dan Heintzman at (304) 652-1766.Thank you for applying with the Friendly Lions Club!!!!! ................
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