APPLETON NOON LIONS CLUB
MONDAY NOON GRAND MERIDIAN
P. O. BOX 762, APPLETON, WISCONSIN 54912
WWW.APPLETONNOONLIONS.COM APPLETONNOONLIONS@GMAIL.COM

Eyecare Referral Form

  1. Applicant Information Form:
    Name: ____________________________________Age:_______
    Address: _________________________________Phone:_____________
    Family Members by age: ___________________________________________

  2. Family Income (monthly):
    Employer:____________________________Monthly Income:_______________
    Employer:____________________________Monthly Income:_______________
    Unemployment:________________________Food Share:___________________
    Social Security: ____________________Other (Specify):______________

  3. Insurance:
    Health Insurance: Yes-No Eyecare Insurance: Yes - No Badger Care: Yes - No

    Are you eligible for government assistance? (DVR-Social Services-VA, etc;) yes - No

  4. Have you had previous help from Lenscrafters? Yes - No Date of Assistance:_______

  5. Who referred you to the Lions Club for help? Self referral: Yes - No or by:_____
    Name:____________________________Agency:___________________________

  6. What type of assistance is requested, and why? (Please answer below):

    Note on the back of the form any other information as you see fit.

    Please return to the address above. We will be in contact with you as soon as possible.
    --Appleton Noon Lion's Club Thank you!

    Form submitted by:
          Name_____________________ Title___________ Phone no._________________

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