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SIGHT PROGRAM ASSISTANCE
Waynesboro Virginia Lions Club - Serving our community since 1934.
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Email *
Date *
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Applicant Name: *
Applicant Address: *
Home Phone:
Cell Phone:
Email Address:
Date of Birth: *
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How long have you lived at this address? *
Are you a citizen of the United States? *
Please indicate which services you are applying for: *
Required
Date of your last eye exam: *
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Doctor: *
Have you received assistance from the Lions Club in the past? *
If yes, when:
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Do you have any vision insurance? *
Please list all members living in your household, including applicant.  Include their name, relationship to applicant, age, employer/source of income, and monthly (gross) income: *
Are you receiving any services from the following? (Check all that apply) *
Required
Referred by (Organization Name)
Address:
Contact Name
Email:
Phone:
I certify that the information on this application is true and correct. I understand that falsifying information will lead to disqualification for any financial assistance. I will not hold the above listed Lions Club liable for any expenses or problems that may arise.

Signature of Applicant:
 *
Signature of Sponsor
CLICK ON "SEND" OR PRINT AND MAIL TO WAYNESBORO LIONS C/O SIGHT CHAIR, PO BOX 211, WAYNESBORO VA 22980 OR EMAIL TO SECRETARY4LIONS@GMAIL.COM
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