Vision Assistance Form

1. APPLICANT INFORMATION

First Name *

Last Name *

Email *

Phone

Who is completing the form? *ApplicantAuthorized Representative

Applicant Street Address

Applicant City

Applicant State

Applicant ZIP

Are physical & mailing address the same?YesNo

Mailing Street Address

Mailing City

Mailing State

Mailing ZIP

Authorized Representative

Representative’s Name

Representative’s Email

Representative Phone

Representative Street Address

Representative City

Representative State

Representative ZIP

Representative RelationshipWhat is your connection to applicant? (e.g. parent, guardian, relative)

More Applicant Information

SexMaleFemale

Age

Birth Date

Are you student?YesNo

If yes, where?

What year/grade?

Are you patient at New Hope Clinic?YesNo

Are you registered with Dept. of Social Services?YesNo

Have you attended a vision screening conducted by the Lions in the past year?YesNo

If yes, where?

If yes, when?

Have you attended a vision screening conducted by the Lions in the past two years?YesNo

2. VISION INFORMATION

Do you suffer from diabetes?YesNo

Has your vision changed substantially recently?YesNo

If yes, briefly explain.

Do you have ANY eyeglasses now?YesNo

If yes, how old are the eyeglasses?

If yes, are they bifocals?YesNo

What is the main trouble with your vision?

What assistance are you seeking?

3. INSURANCE INFORMATION

Are you a veteran?YesNo

Do you receive Veteran’s Assistance?YesNo

Do you receive Medicaid?YesNo

Do you receive Medicare?YesNo

Do you have other insurance?YesNo

If yes, insurance company’s name

Does insurance pay for medications?YesNo

If yes, what percentage?

Any other means of possibly obtaining assistance, including family members or friends?YesNo

If yes, please explain

4. EMPLOYMENT & INCOME INFORMATION

Employment status *EmployedUnemployed

Current employer

Length of time

Current employer address

What is your gross monthly income?

How long have you been unemployed?

Reason for unemployment

Previous Employer

Address

Date ended

Other sources of incomeIf unemployed, what other monthly income do you have?

What is the total gross monthly income of the household you are living in?(Include, but not limited to: welfare assistance, social security, alimony, child support, other, and applicant)

How many adults living in household?(18 years and older)

How many children living in household?(Under 18 years)

Will you be able to help (in any way) for the Vision Assistance you are requesting?YesNo

If yes, how much?

5. APPLICANT EXPECTATIONS

Applicant should expect

Lion coordinator will contact you to confirm your information and other factors involving your situation.
Lion coordinator will advise you if you have been accepted, rejected, or if more information is needed.
Upon being accepted, the Lions Coordinator will mail you a letter, noting your acceptance and that you have thirty-one (31) days to the expiration date noted on the letter to complete your Upon receiving the letter you should make your appointment, take the letter with you to the appointment. Without the letter, Wilmington Eye will not honor your appointment.
If you have not completed your appointment within thirty-one (31), the expiration date on the letter, your application is considered expired and invalid. In this case you would have to apply again for assistance, which is not usually approved for at least a year and sometimes two years.

Certification

I hereby affirm that, to the best of my knowledge and belief, the information provided in this application is true and complete. I understand and hereby authorize the Southport Lions Foundation Inc., to make a complete investigation of all the statements made herein.

I understand that the completion of this form in no way obligates the Southport Lions Foundation, Inc to provide the requested assistance, as actual funding is discretionary depending on need and availability of funds.

I also understand that if I obtain assistance by false representation, all funds advanced on my behalf will be due and payable. I will inform the Southport Lions Foundation, Inc. if any of the above information changes within 7 days of any change. I have not obtained Vision Assistance from any Lions Club or Lions Foundation in the past two years.

I understand that my appointment with the assigned doctor must occur within thirty-one (31) days, the expiration date noted on the letter, after which time the approval is considered expired and invalid. The Lions’ assistance is for this appointment. If the doctor requests additional appointments, the applicant is to contact the Lions prior to proceeding with additional appointments.

Do you agree to the terms of this application? *Yes

Programs

Brighter Visions