Lions Eyeglass Assistance Program

Lions Eyeglass Assistance Program
FOR USE BY LIONS CLUBS ONLY
Applicant: Complete Sections 1, 2, and 3 and submit this application along with any requested documentation to the Lions Club listed in Section 4. You will be notified of your application status by the Lions Club Volunteer.

Applications are generally processed within several weeks but are dependent on staff and volunteer availability. Your patience with this volunteer driven effort is appreciated. Upon qualification, you are eligible for clear plastic or polycarbonate single vision, lined bifocal or lined trifocal lenses.

Section 1: Applicant Information (please print)
Type of Request

Eye Exam and GlassesGlasses only (I have a current prescription)
Name*

Applicant First NameApplicant Last Name
Applicant preferred name if different than first name given
preferred name
Applicant Date of Birth*

MonthDayYear
HOME Address (if houseless, where do you usually reside)*

Physical Address

Apartment #

CityState

Zip Code
Phone (primary number to contact you)*
Primary phone number
Secondary Phone
Secondary phone number
County
Email
example@example.com
Mailing Address (if different from Home Address)

Mailing Address

Street Address Line 2

CityState

Zip Code
Number of People in Household?*
How long have you lived in OR/Northern CA? (mm/yyyy)*
Occupation
Preferred Written or Spoken Language(s)
Who can we call with questions?

YourselfOther
If other
Name
Phone Number
Please enter a valid phone number.
Relationship to you:
PLEASE NOTE: YOUR APPLICATION WILL NOT BE REVIEWED UNLESS PROOF OF INCOME IS INCLUDED.

Proof of income may be: pay stubs from the last 2 recent pay periods, current DHS/TANF/SSI/Disability award letters, food stamp benefit letter, or awards letters from other government or state assistance programs.
MONTHLY INCOME

BEFORE Taxes and Deductions
Applicants Wages
Applicants wages
Spouse/Domestic Partner's Wages
Spouse/Domestic Partner's Wages
Welfare Benefits
Welfate Benefits
Social Security/Disability
SSI/SSD
Food Stamps
Food Stamps
Other
Other income
Total Monthly Income*
Total Monthly Income
Do you have VISION Insurance?*

YesNo
If Yes, please explain why you are requesting help from the Lions?
When was your last exam?
If approved, please send my certificate to:*
Please send my certificate to:
Section 2: Authorization for Release of Information
I agree that my Lions Club in Section 4, the Oregon Lions Sight & Hearing Foundation, and their qualified partners and providers, may review and share between themselves the personal and income information I included with this application along with any additional information about my vision, such as an eyeglass prescription.
Authorization for release of Information - Sight & Hearing Foundation

YesNo
I agree to participate in and allow the Oregon Lions Sight & Hearing Foundation permission to use general interest information/quotes/photographs of myself for publicity, promotion, news releases, videos, and web use of the Oregon Lions Sight & Hearing Foundation. I hereby release and discharge the Oregon Lions Sight & Hearing Foundation from any and all claims arising out of the use of the above stated purposes that I may have in this regard.
Authorization for release of information - general information for publicity, etc.

YesNo
I understand that I may revoke these authorizations in writing at any time by faxing a signed and dated letter to (503) 413-7522, except to the extent that the organization(s) named above may have acted in reliance on this authorization. I have had the opportunity to read and consider the contents of this authorization.
Applicant or Guardian Signature

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Date

MonthDayYear
Section 3: Fitting Fee Agreement
Depending on the provider your Lions Club is working with, there may be a $25 copay when you receive your eyeglasses fitting. Please be prepared to pay that copay or provide an explanation on a separate sheet of paper as to why that cost would be a hardship for you at this time. Your local Lions Club will let you know about the copay when they process your request for assistance.
Signature

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Date

MonthDayYear
Section 4: Lions Club Contact Information

Coos Bay Lions Club PO Box 3, Coos Bay OR 97420 541.297.4474
Should be Empty:

Lions Eyeglass Assistance Program

FOR USE BY LIONS CLUBS ONLY

MONTHLY INCOME

Section 2: Authorization for Release of Information

Section 3: Fitting Fee Agreement

Section 4: Lions Club Contact Information