FWB LIONS CLUB APPLICATION FOR EYE EXAM AND/OR EYEGLASSES
Please print this page, completely fill out application and mail to:
Fort Walton Beach Lions Club
P O Box 844
Fort Walton Beach, FL 32549
Date__________Name_______________________________________DOB__________
Age____ Sex_____ If a Minor, Parent/Guardian’s Name____________________________
Phone____________Address____________________________City___________Zip_______
Occupation________________Employer_________________________Phone_________________
If not currently employed, how long unemployed______________________________
Own Home?_______ Rent Home?______ Approximate Current Debts______________
Veteran__ YES________NO______ SSI YES______NO______
Can Family pay for part of these services? _______
Have you received Lions Club Assistance in the past__________
Do You Have:
Private Health Insurance?____ Medicare?_____ Medicaid?_____ Other Public Assistance?______
YOUR FINANCIAL SUMMARY:
Number of Family Members Living in the Household: #Adults ______#Children__________
Monthly Household Income Average Monthly Household Expenses
Applicant’s Take Home Pay $________________ Rent/Mortgage $__________
Spouse’s Take-Home Pay $________________ Food $_________________
Parent/Guardian’s Take Home $_______________Utilities $________________
Social Security Benefits $____________________Telephone $______________
Disability Benefits $_________________________Medical Expenses $__________
Retirement/Pension $_______________________ Car/Transportation $_________
Veteran’s Benefits $_________________________Auto. Payment $_________________
Unemployment Benefits $_____________________Car Insurance $_________________
Federal/State Public Assistance $______________ TV/Cable/Internet $_________________
Child Support/Alimony $_______________________Child Care $_________________
Food Stamps $_________________ _____________Other Expenses $_________________
Other Income $_________________
Total Monthly Income $________________________Total Expenses $____________
Date of last eye exam: _____________Do you have glasses?_______Are they broken?____
Give reasons why you feel the Lions should help (use reverse if necessary)_______________________________________________________________________
I HEREBY CERTIFY that the above statements are true and that I cannot pay for the services requested without undue hardship.
Signature__________________________________ Name (Print) _____________________________
If signing as a personal representative or if the above is a minor, please indicate relationship.
