VSP Request Form
I, the Sight & Hearing Chair for my club, agrees that we fall into the guidelines above AND we will comply with the vetting and follow up with our client.
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Client's Information
Client's Full Name
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First Name
Last Name
Client's Date of Birth
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client's Mailing Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client's Residing County
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Client's Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Client's Email
example@example.com
How Many People Are in the Client's Household
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Does Client have Vision Insurance
What insurance do they have?
Client's Total Monthly Gross Income
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Client's Source of Income
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Please Select
DHS Benefit Letter
Paystubs
Previous Year's Tax Return
SNAP Benefits Letter
Social Security Benefits Letter
Social Worker/Case Manager
TANIF Benefit Letter
Other
If Other, please explain
Does the Client Want to Comment or Share their Story?
Lions Club Information
Which Lions Club are You Associated With?
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What is Your Name?
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First Name
Last Name
What is Your S&H Chair Email Address?
example@example.com
What is Your Preferred Phone Number?
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Please enter a valid phone number.
Format: (000) 000-0000.
What is Your Preferred Mailing Address?
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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