Vision Assistance Form

Bremerton Central Lions Club Vision Assistance Application

PO Box 353, Bremerton, WA 98337
Date

MonthDayYear
Your Name

First NameLast NameSuffix
Birthdate*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Referral Agency

Name

Street Address

CityState / Zip Code
Assistance Requested*
Vision Issues*
Name of Eye Doctor who performed last exam:

Name

Location

Approx Date of examState / Province

Postal / Zip Code
Do you currently have satisfactory frames?

YesNo
Do you have a current eye prescription?

YesNo
Other Information Needed: *
Number of Dependents:

Number ______________Age _______Age _______Age _______
Medical Coverage, if applicable

Company

State / Province

P
Are glasses or hearing aids covered?

YesNoI don't know
Briefly describe your financial status *
By signing this application for assistance for the item(s) checked above, I agree to be bound by the decision of the Sight and Hearing Committee of the Bremerton Central Lions Club and understand that all decisions are final. I agree that any expenses incurred by me over the amount authorized by the Club are my sole responsibility, and Iagree to pay for them at the time the service is provided. I agree to provide, uponrequest, any financial, medical or other information that may be requested by anauthorized representative of the Bremerton Central Lions Club for the purpose ofdetermining my eligibility for assistance. I agree that the Club may contact any other party who may have knowledge of my situation and agree to hold them harmless for anyinformation provided.
Applicant (if over 18) or Parent/Guardian Signature

Date

Bremerton Central Lions ContactPhone

Postal / Zip Code
For Use by Bremerton Central Lions

Date Application Received:

Date

Control Number: Phone

Postal / Zip Code
Board Action:

ApprovedDeniedAmount Paid _____________Follow Up Action ______________________________________________________________________________________________________________________________________________________________________________________________________
Should be Empty:

Bremerton Central Lions Club Vision Assistance Application