Eye Assist Vision Program eForm
UPDATE: All submissions are processed on Fridays and are mailed out over the weekend via USPS.

In 1925, Lions Clubs International featured Helen Keller as the guest speaker. Through her interpreter, Helen Keller challenged the Lions to constitute themselves as “Knights of the Blind” in a crusade against blindness. As a result, Lions Clubs International sponsors thousands of programs for the blind and visually impaired around the world each year. In collaboration with Cane Island Katy Inc, your local Lions Club answers this call in multiple ways, including by offering low-income individuals glasses at little to no cost to them or their families. You can learn more about your local club by visiting www.beagreatlion.org or calling (713) 714-6789.

Your local Lions Club offer glasses through the VSP Eyes of Hope certificate program. Approved certificates will be mailed to the school nurse or referring agency partner to provide to the family directly. Instructions for redemption are provided on the certificate in English. Eligibility Guidelines: To use a VSP Eyes of Hope certificate, the patient must:
  1. Have a family income at or under 200% of the Federal Poverty Level guidelines
  2. Not have used a VSP program in the last 12 months;
  3. Not have coverage through a private insurer or government program for the eye care services or prescription eyewear covered by this certificate.
Note to referral partners: For existing (listed) referral partners, your submission constitutes approval, as you have already completed an internal needs assessment. We will automatically send out the voucher by USPS to your campus when we process all voucher requests on Fridays. For non-listed referral partners, we may contact you to confirm your submission prior to mailing out the voucher. Eligible recipients will be reported as a member of a Leo Club at no cost or participation requirement. This submission affirms parental permission.
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Email *
Referring Agency *
Referrer Name *
For schools, this is the school nurse. For agency partners, this is the approved counselor or qualified individual.
Referrer Phone Number (include area code) *
Referrer Campus *
Include complete mailing address for referrer campus. This would be the school's name & address, or for agency partners, the office address of the qualified individual who completed the referral.
Recipient First & Last Name *
Recipient Date of Birth
*
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A copy of your responses will be emailed to the address you provided.
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