Caldwell Lions Club Vision Application 
If you need assistance with eye exams or glasses please fill out the following form and submit it to the club. A Lions club member will then contact you. Thank you!  Please make sure to fill out the ENTIRE application otherwise we may not have enough information to approve your application. 
Email *
Date of application
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Name of Applicant 
Address of applicant
Date of Birth
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phone number 
Date of last eye exam
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Name of parent or guardian 
Income questions: Family Monthly Income
Salary after taxes 
Social Security Benefits 
Veterans Benefits
Aide to dependent children 
Child support

Food Stamps 
Total monthly Income 
Income Questions: Family Monthly Expenses 
Rent/Mortgage
 
Car Payment/car expenses 
Utilities expense
Food expense
Insurance expense
Medication/Doctor expense
Other expenses: please list 
Total Monthly Expenses
Number of people in household 
Do you currently have a medical card 
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Have you ever applied for a medical card? 
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Do you have medical or vision insurance? 
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List all current diagnosed medical conditions: 
Reason for requesting assistance? 
Who referred you to the Lions Club? 
Certification: I certify that the above information is complete and accurate to the best of my knowledge and belief. Please digitally sign your name below
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