ELKHART LIONS CLUB
Eyeglass Assistance Program Application
(for children living in the Elkhart Community Schools attendance area)

PRINT THIS PAGE, COMPLETE AND RETURN TO ADDRESS BELOW.

Name of Parent or Guardian___________________________________________
Address________________________________________________City_______________Zip______
Home phone________________Work phone____________Number in household________
If working, name of employer______________________________________________________
Full name, age, & school of child(ren) needing assistance.
Use a separate sheet for additional  names.
1.__________________________________Age_____School________________________________
2.__________________________________Age_____School________________________________
3.__________________________________Age_____School________________________________

Are any of the names listed above:                                     Yes       No     
    Enrolled in or eligible for Medicaid?                                 ____     ____     
    Eligible for insurance that covers eye exams or glasses?    ____     ____     
    Recipients of previous Lions Club assistance?                   ____    ____  
    Currently wearing eyeglasses?                                          ____    ____  
    Eligible for free school lunch?                                            ____    ____     
What is the total gross income of all people in your household?
    Income is $_____________ per week_____biweekly_____month_____year______
Place a check (P) beside your sources of income: Wages_____AFDC______
    Social Security_____Disability_____Pension_____Child Support_____ 
    Supplemental Aid______Unemployment______Other_____
Give the name & location of your eye doctor._____________________________________
Who referred you to Lions Club?___________________________________________________
Describe any special circumstances we should consider.________________________
______________________________________________________________________________________
                                        STATEMENT OF UNDERSTANDING
To qualify for assistance applicants must: 1) answer all questions honestly and completely, 2) submit documentation for their responses upon request, 3) use the services of an eye doctor located in Elkhart County, 4) schedule their own eye care appointment within 60 days after receiving a Lions approval letter. After providing eye care service, the doctor will bill the Elkhart Lions Club directly and be paid up to $115.00 per eligible person.

 Signature of Parent/Guardian____________________________________________Date_____________