Lions Eyeglass Application - MartyJuel
ELKHART LIONS CLUB
Eyeglass Assistance Program Application
Name of Parent, Guardian or Responsible Person_________________________________________________
Address________________________________________________________________ Zip___________
Home phone____________________ Cell or Work phone__________________ Number in household_______
If working, name of employer_______________________________________________________________
Full name, age, & relationship to Applicant of person(s) needing assistance.
Use a separate sheet for additional names.
1._____________________________________________Age_____Self___Spouse____Child____Other____
2._____________________________________________Age_____Self___Spouse____Child____Other____
3._____________________________________________Age_____Self___Spouse____Child____Other____
List school of any child above________________________________________________________________
Are any of the names listed above:
Yes No
Enrolled in or eligible for Medicaid?
____ ____
Eligible for insurance that covers eye exams or glasses?
____ ____
Recipients of previous Lions Club assistance?
____ ____
Currently wearing eyeglasses?
____ ____
Eligible for free school lunch?
____ ____
What is the total gross income of all people in your household?
Income is $____________________ per ( ): week_____ biweekly_____ month_____ year______
Place a check () beside your sources of income: Wages_____ AFDC______
Social Security_____ Disability_____ Pension_____ Child Support_____
Supplemental Aid______ Unemployment______ Other_____
Give the name & location of your eye doctor.___________________________________________________
Who referred you to Lions Club? ____________________________________________________________
Describe any special circumstances we should consider._________ __________________________________
_____________________________________________________________________________________
STATEMENT OF UNDERSTANDING
To qualify for assistance applicants must: 1) answer all questions honestly and completely, 2) submit documentation for their responses upon request, 3) use the services of an eye doctor located in Elkhart County, 4) schedule their own eye care appointment within 30 days after receiving a Lions approval letter. After providing eye care service, the doctor will bill the Elkhart Lions Club directly and be paid up to $80.00 per eligible student or $100.00 per eligible adult.
Applicant's signature__________________________________________ Date _______________________
Complete Application And Mail or Fax To:
574 293-1292
Diane E. Parker Eyeglass Assistance Chairperson Elkhart Lions Club P.O. Box 81 Elkhart, IN 46515
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