- We collect used eyeglasses to share with others in need. If you have eyeglasses that you would like to donate, please contact any club member.
Eyeglass drop off locations
- Palmerton High School
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Eyeglass Assistance
With monies raised through the support of our community, Palmerton Lions Club is able to offer financial assistance to persons in need of eyeglasses. Determination is made based on a physician's referral and completion of a brief questionnaire. For information or an application, please contact:
- James Sheckler at 610.826.4533
- Steve Oreovec at 610.826.8251
- Claire Heiny at 610.826.4978
Palmerton Lions Club Eyeglass Policy and Financial Application
Policy Title: Eyeglass funding
Policy Drafted: February 12, 2012
Drafted by: Eyeglass committee
Date Approved: February 20, 2012
______________________________________________________________________________________
Purpose
The board of directors will authorize the formation of an eyeglass committee whose responsibility will be to establish a policy & request form for funding and make recommendations to the board of directors and the membership regarding the granting of funds to purchase eyeglasses for individuals with financial need.
Procedure
The individual with financial need will contact a member of the committee.
The committee member will provide requestor with an application.
The application will be completed in its entirety by the requestor and will be given to/mailed to the club.
If the application is incomplete, it will be returned to requestor by the committee and will not be re-evaluated until it is considered acceptable.
The eyeglass committee will review the application for need and will make a recommendation to the board of directors and the membership and will note this on the application.
Following approval a member of the committee will contact the requestor with the club’s response. The committee reserves the right to ask questions related to the need for eyeglasses and/or funding and also reserves the right to deny a request.
If the decision is made to provide funding, it will be provided directly to the business where the eyeglasses are to be purchased.
The requestor is responsible for making all appointments and transportation arrangements. The club will not assume this responsibility.
A receipt for purchase will be required from the requestor or the business where the eyeglasses are to be purchased.
All requests must be made and approved in advance. Retroactive requests will not be considered.
Funding will only cover eyeglasses and will not cover eye examinations, designer frames, tinting, contact lenses, LASIK surgery, etc.
Funding will only be provided to residents of Palmerton area.
If having cataract surgery, eyeglasses will not be funded until after the requestor has surgery and physician determines that correctives lenses are appropriate.
Each applicant will receive a maximum up to $150.00 for eyeglasses.
Palmerton Lions Club
Eyeglass Funding Application
Applicant □Adult □Minor (√ one)
Date of application________________________________________ DOB of applicant______________
Name______________________(Last) ______________________(First) _________(Middle initial)
Address_______________________________________________________________________________
______________________________________________________________________________________
Telephone ( )________________________ Email address_______________________________
Date of Appointment with eye doctor______________________________________________________
Name of eye doctor___________________________________________________________________
Address of eye doctor_________________________________________________________________
___________________________________________________________________
Are you scheduled for cataract surgery within the next year? □Yes □No
Reason for funding request (Use separate sheet if necessary, but please be brief)
______________________________________________________________________________________
______________________________________________________________________________________
Are you currently working? □Yes □No If no, explain__________________________________
If yes, occupation _______________________ Employer_________________________________
Is anyone in your household working? □Yes □No If no, explain___________________________
What is your annual household income? $__________________________________________ annually
Include Social Security, SSI, Pension, Veteran’s benefits, retirement, Life insurance premiums, Public Assistance/Welfare, Child Support &/or unemployment compensation.
Total number residing in your household_____________
The maximum funding available for eyeglasses is up to $150.00. Do you have the remaining funds to pay for your eyeglasses? □Yes □No
If no, how do you anticipate obtaining the remainder of the funding? ______________________________
Do you have funds to pay for your eye examination? □Yes □No
If no, how do you anticipate obtaining the funding to do so? ____________________________________
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Eyeglass Funding Application – Page 2
Name of applicant _______________________________________________________
Monthly expenditures
Mortgage/Rent $__________
Food $__________
Heating $__________
Cable $__________
Water/sewer $__________
Garbage $__________
Clothing $__________
Auto loan/lease $__________
Other (specify) $__________ List additional expenses______________________________________
TOTAL $__________
How did you find out about our eyeglass program? _________________________________________
__________________________________________________________________________________
Although this is not a stipulation for you to obtain funding, are you willing to assist with any of our club’s service projects? □Yes □No
By signing below, I verify that all information I have provided on this application is accurate. In addition, I grant the Lehighton Area Lioness Lions Club permission to verify the accuracy of the data. I understand that if any inaccuracies are found, that the agreement for funding, if provided, will be withdrawn. I further agree to provide a copy of the receipt for my eyeglasses to the Palmerton Lions within 2 weeks of receipt of the eyeglasses.
____________________________________________________ _____________________________
Signature of applicant or Legal representative Date
Please mail completed application to:
Attn: Eyeglass Committee
Palmerton Lions Club
Palmerton PA 18071
Please do not write below this space
______________________________________________________________________________________
Official Use Only
□Funding denied by committee □Funding approved by committee
□Funding denied by BOD/membership □Funding approved by BOD/membership
Amount approved $_________________ Check #________________ Date__________
Committee members’ signatures
___________________________________ ___________________________________
___________________________________ ___________________________________
___________________________________ ____________________________________
