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GET HELP FORM for Sight/Hearing
All fields with an asterisk must be filled out before you can submit this referral. This referral will be sent to the Lions Club in your area. NOTE: The Lions Club volunteer members will mail/make available a paper application as soon as they are able to assist.
Name of Person Needing Help
*
First Name
Last Name
Name of Person Making Referral (if Different from Person Needing Help)
Phone Number of Person Making Referral (If Different from Person Needing Help)
Format: (000) 000-0000.
Email of Person Making Referral (If Different from Person Needing Help)
Primary Language Spoken by Client
The Age of the Person Needing Help
*
The person needing help is 21 years of age or older
The person needing help is 16-20 years old and is NO LONGER attending high school or high school equivalent
The person needing help is 16-20 years old and IS ATTENDING HIGH SCHOOL or high school equivalent
The person needing help is 0-15 years old
Home Address of Person Needing Help (If Houseless, please enter the address of an organization, shelter or person close to where you stay most often, so that if you are approved, we can connect you with a Lions Club and provider near you)
*
Mailing Address of Person Needing Help (If Different from Home Address; if Houseless, please enter a deliverable address of an organization, shelter or person who is able to receive mail on your behalf)
Phone Number of Person Needing Help or for Contact Person
*
Format: (000) 000-0000.
Alternate Phone Number of Person Needing Help
Format: (000) 000-0000.
Email of Person Needing Help
Type of Help Needed
*
Follow-up if you haven't heard back from a Lions Club regarding a request you have made or an application you have submitted
Eye Exam and/or Eyeglasses
Eyeglasses Only (must have a non expired eyeglass prescription)
Hearing Test and/or Hearing Aids
Help with a Vision/Hearing Related Surgery or Procedure
Other (please provide more information on what you need help with in the section below)
Vision/Hearing Related Surgery or Procedure Type
Cataract Surgery
Corneal Cross-Linking Procedure
Emergency Services
Intravitreal Injections
Prosthetic Eye
Pterygium Removal
Serum Eye Drops
Other (please provide more information on what you need help with in the section below)
Tell Us More About the Help You Need (and if you're currently Houseless, please add any necessary details concerning address or contact information)
Home Address - No Longer used; replaced with integration: LOB Address verification field - removed/hidden 1/8/22 MP
Street Address (may leave blank if houseless)
Apartment / Suite / Space #
City
State
Home Zip Code (if Houseless, Zip Code where you reside most)
My Mailing Address is Different - not sure if we ever used this field - MP
Click Here to Add Mailing Address
Mailing Address of Person Needing Help (If Different from Home Address) - - No Longer used; replaced with integration: LOB Address verification field - removed/hidden 1/8/22 MP
Street Address
Apartment / Suite / Space #
City
State
Zip Code
Are you over the age of 21? - No Longer used - was not supposed to be a multiple choice field - hidden/removed on 1/8/22 MP
Yes
No
Certification: By submitting this request, I am agreeing to only seek help from the Lions if I do not have existing insurance coverage or other funding options. I will be required to disclose any insurance coverage I have to the provider at the time of my appointment
I agree
Submit
Should be Empty: