Date: Click or tap to enter a date.

Name: Click or tap here to enter text.

Address: Click or tap here to enter text.

Phone: Click or tap here to enter text.  Household Size: Click or tap here to enter text.

Annual Income: Click or tap here to enter text.

Please include proof of income (attach scanned copies of recent pay stubs, government assistance letters, or other documentation).

Please include a photo of your Florida Driver’s License or Florida ID Card.

Current eyeglass prescription summary if applicable: Click or tap here to enter text.

Request (check all that apply): ☐ Eye Exam ☐ Glasses ☐ Hearing Aid(s)

You may qualify if your total monthly income is at or below 200% of the poverty level and you do not have vision coverage. Some programs also require that you have a current eyeglass prescription or the ability to pay a small, affordable fee for glasses.

Please email the completed application to visionandhearingassistance@scclions.org