Vision Assistance

Orange Lions Club

Ages of other dependents in household *

Number of incomes in household *

If other, please explain

Requested assistance previously from other non-profits? *

Yes

City *

Zip *

Household Monthly Income *

Phone Number *

Apartment/Unit

How long has the individual requesting assistance lived in Orange County? *

Zip *

Any existing insurance coverage? *

Name of person requesting assistance *

Parent/Guardian name if individual above is a minor

Received assistance previously from Lions? *

Yes

Other dependents in household *

Email: *

Number of Other Dependents in Household *

Number of Children in Household *

How long have you lived in Orange County? *

Work hours *

Full time

Part time

Not applicable

Type of Employment

Full Time

Part Time

Gender *

Employer (enter 'student' if a minor) *

Email: *

Date of Birth *

Vision Assistance Request Form

Number of Children in Household *

Phone Number *

Email: *

Type of work *

Full Legal Name of Individual Requesting Assistance: *

Date of birth *

City *

Sex *

Male

Female

Number of Adults in Household *

Requested assistance from other non-profits? *

Yes

Phone Number *

Current Need *

Vision exam

Glasses

Both

Other

Gender *

Zip *

Employer (enter 'student' if a minor) *

Ages of children in household *

Any existing insurance coverage? *

Other Pertinent Information

Date of Birth *

State *

Gender

Male

Female

Please note that all information provided will remain confidential and is solely used to determine assistance that we can provide.

Number of Other Dependents in Household *

Gender

Male

Female

Number of adults in household *

Number of Adults in Household *

Household Monthly Income *

How long have you lived in Orange County? *

Street address *

Parent/Guardian Name (N/A if individual requesting assistance is over 18) *

Vision Need *

Vision Exam

Glasses

Both

Other (please include specifics in next section)

Household Monthly Income *

Employer *

Apartment/Unit

State *

Parent/Guardian Name (N/A if individual requesting assistance is over 18) *

Number of children in household *

Apartment/Unit

City *

Other Pertinent Information

Vision Need *

Vision Exam

Glasses

Both

Other (please include specifics in next section)

Full Legal Name of Individual Requesting Assistance: *

Street Address *

Type of Employment

Full Time

Part Time

Street Address *

State *