THE WHEELING LIONS CLUB
APPLICATION FOR SIGHT CONSERVATION
NAME OF APPLICANT:____________________________________ AGE: ________DATE:______________
ADDRESS:______________________________________________________PHONE:____________________
NAME OF PARENT OR GAURDIAN:_____________________ OF SPOUSE:_________________________
NUMBER OF DEPENDENTS:__________________AGE OF DEPENDENTS:_________________________
TOTAL (MONTHLY) INCOME:________________OTHER SUPPORT RECEIVING:_________________
EMPLOYER:_________________________________ IF NOT EMPLOYED, DATE
LAST WORKED:______________________________
ARE YOU LOOKING FOR WORK?___________________WOULD YOU ACCEPT
MINIMUM WAGE?_______________________
IF NOT, WHY NOT?_________________________________________________________________________
OWN OR BUYING HOME:_________RENTING:__________MONTHLY PAYMENT/RENT:___________
NEAREST RELATIVE WITH WHOM NOT LIVING WITH YOU:__________________________________
ADDRESS:________________________________________________PHONE:__________________________
FAMILY DOCTOR:__________________________________DO YOU WEAR GLASSES NOW?_________
WHO DID YOUR LAST EYE EXAM?___________________________WHERE?_______________________
DO YOU HAVE ANY INSURANCE TO PAY PART OR ALL COST OF GLASSES/EXAM?____________
DO YOU HAVE A WEST VIRGINIA HUMAN SERVICES (WELFARE) MEDICAL CARD?___________
DO YOU HAVE ANY ABILITY TO CONTRIBUTE TO COST OF GLASSES/EXAM?_________________
COMMENTS TO HELP COMMITTEE DECIDE TO APPROVE:___________________________________
____________________________________________________________________________________________
SIGNATURE OF APPLICANT, PARENT OR GAURDIAN: _______________________________________
PLEASE NOTE: APPLICATION MUST BE COMPLETED IN FULL TO BE CONSIDERED. YOU MAY BE CONTACTED FOR ADDITIONAL INFORMATION. SIGHT COMMITTEE RESERVES THE RIGHT TO VERIFY ANY INFORMATION PROVIDED. A TELEPHONE NUMBER WHERE YOU CAN BE REACHED IS A MUST!