Meetings

LIONS VISION CARE, INC.
PO BOX 64
VALPARAISO, IN 46384-0064

Questions: Call Lion Bev Collinsworth, 219-242-4828

GRANT APPLICATION

NAME_________________________________________________________________

ADDRESS_____________________________________________________________________________________________________________________________________________________________________________________________________________

PHONE__________________________________ AGE ________________________

REFERRRED BY:______________________________________________________

HOW DOES YOUR VISION IMPAIR YOU FROM PERFORMING EVERYDAY TASKS?_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HOW LONG HAVE YOU BEEN VISUALLY IMPAIRED?______________________________

EYE DOCTOR_______________________________________________________________________

HAVE YOU APPLIED FOR OTHER SOURCES OF FUNDING (i.e. Dept. of Vocational Rehabilitation, Medicaid, etc.)?_______________________________________

HAVE YOU HAD A CURRENT EYE EXAM?_________________________________________

HAVE YOU HAD A LOW VISION EVALUATION?___________________________________

WHAT APPLIANCES OR DEVICES DO YOU NEED AND WHAT IS THE COST OF THESE ITEMS? _____________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

WE WILL REQUIRE VERIFICATION FROM YOUR EYE DOCTOR.  Please have your doctor fill in the reverse side of this form.

VISION REQUIREMENTS FOR GRANT ACCEPTANCE:

  1. Best corrected vision of 20/50 or worse in the better eye

Or

      2.A visual field defect that is debilitating.

       3.  Must be a resident of northwest Indiana.

 

 

 

 

 

 

 

Dear Doctor:

          Lions Vision Care, Inc is a charity incorporated to help the visually impaired of northwest Indiana.  __________________________

has approached us for a grant to help fund low vision rehabilitation.  The following information is needed to be certain that the individual qualifies under our guidelines:

  1. Best corrected visual acuity in each eye                      O.D. _____________________O.S. _________________________
  2. Any field defects____________________________________________
  3. Diagnosis:___________________________________________________
  1. Low vision recommendations: _____________________________

 

Please release information to:     LIONS VISION CARE, INC

                                                          PO BOX 64

                                                          VALPARAISO, IN 46384-0064

Patient’s name: ______________________________________________________

Address ______________________________________________________________ DATE :

 

SIGNATURE __________________________________________________________

 

 

 

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