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:
- 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:
- Best corrected visual acuity in each eye O.D. _____________________O.S. _________________________
- Any field defects____________________________________________
- Diagnosis:___________________________________________________
- 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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