“WE SERVE”

STROUDSBURG LION’S CLUB

Stroudsburg Lion’s Club Eyeglass Referral Form

Name ________________________________________ Date _______________________

Birth date ___________________

Phone Number Home____________________________ Cell________________________

Address____________________________________________

             ____________________________________________

             ____________________________________________

Who referred you to the Lion’s Club for eyeglasses? ________________________________

__________________________________________________________________________

State briefly why you need our assistance with the purchase of an eye exam and eye glasses?

__________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Do you have VISION / eye insurance?     YES or NO

Do you have Medical Assistance?           YES or NO

If YES, what is the name of your insurance company? 

__________________________________________________________________________

Send this form to:

Stroudsburg Lions Club Vision Program

c/o David D. León

262 Five Springs Rd. 

Stroudsburg PA 18360-8276

Filled forms can be emailed to:  stroudsburglions@gmail.com