Meetings

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_________________________

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