OLEAN LIONS CLUB INTAKE-EYEGLASS REFERAL
SEND FORM TO RAY GREEN 215 S. 10TH ST. OLEAN, NY 14760
NAME________________________________DATE________________MALE_____FEMALE_____
ADDRESS__________________________CITY__________________STATE_____
ZIP CODE______
TELEPHONE__________________CELL_____________ COUNTY _______________________
DATE OF BIRTH___________SOC SEC#__________________________MEDICAID YES NO
PARENT OR GUARDIAN NAME_______________________________IF APPLYING FOR CHILD
ADDRESS IF DIFFERENT FROM CHILD________________________________________________
CITY____________________STATE_________ZIPCODE_______________ADVOCATE_________
EDUCATION LEVEL______________RACE____________DISABILITY-LOW VISION
REQUEST FOR:
EXAM_________
LENSES ONLY_______
EXAM, FRAMES, AND LENSES________
PLEASE LIST ALL FAMILY MEMBERS RESIDING IN YOUR HOUSE:
1.__________________________________DATE OF BIRTH______________
2. .__________________________________DATE OF BIRTH______________
3. .__________________________________DATE OF BIRTH______________
4. .__________________________________DATE OF BIRTH______________
5. .__________________________________DATE OF BIRTH______________
REQUEST FOR EYEGLASS PURCHASE- FINANCIAL AID INFORMATION
HOUSING RENT/MONTH________ MORTGAGE/MONTH________
UTILITIES/MONTH HEAT________ ELECTRIC________TELEPHONE________
WATER/SEWER_______
OTHER COSTS/MONTH
TO WHOM
OWED_________________________________________AMOUNT/MONTH___________
TO WHOM OWED_________________________________________AMOUNT/MONTH___________
TO WHOM OWED_________________________________________AMOUNT/MONTH___________
TO WHOM OWED_________________________________________AMOUNT/MONTH___________
INCOME
TOTAL EARNINGS /MONTH
SOURCE______________________________________AMOUNT______________/
SOURCE______________________________________AMOUNT______________/
SOURCE______________________________________AMOUNT______________/
I HEREBY CERTIFY THAT THE INFORMATION PROVIDED IN THIS REQUEST IS TO THE BEST OF MY KNOWLEDGE TRUE.
SIGNATURE OF APPLICANT/GUARDIAN_______________________________DATE__________
PRINT NAME_________________________
