Vision Assistance

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 *

How long have you lived in Orange County? *

Work hours *

Full time

Part time

Not applicable

Type of Employment

Full Time

Part Time

Gender *

Date of birth *

City *

Gender *

Zip *

Ages of children in household *

Any existing insurance coverage? *

Other Pertinent Information

Date of Birth *

State *

Requested assistance previously from other non-profits? *

Yes

City *

Received assistance previously from Lions? *

Yes

Date of Birth *

Sex *

Male

Female

Employer (enter 'student' if a minor) *

Orange Lions Club

Apartment/Unit

Email: *

Type of work *

Current Need *

Vision exam

Glasses

Both

Other

Vision Assistance Request Form

Full Legal Name of Individual Requesting Assistance: *

Phone Number *

Name of person requesting assistance *

Number of Children in Household *

Email: *

Requested assistance from other non-profits? *

Yes

Ages of other dependents in household *

Number of incomes in household *

Zip *

Number of Other Dependents in Household *

Number of Adults in Household *

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

Email: *

Apartment/Unit

Parent/Guardian name if individual above is a minor

Number of Children in Household *

Zip *

Any existing insurance coverage? *

Phone Number *

If other, please explain

Phone Number *

Employer (enter 'student' if a minor) *

City *

Other dependents in household *

Household Monthly Income *