Eyeglass Assistance Request

Applicant Name *

Enter the name of the person applying for an eye exam and/or eyeglasses

Applicant Date of Birth *

Applicant Address *

Applicant Address

City

State/Province

Zip/Postal

Applicant Phone Number *

Applicant Email *

Describe the justification and financial need *

Describe the applicant's inability to pay for an exam and glasses. Does the applicant have a job? Have insurance? Does the insurance cover eye exams? Do they receive medical assistance?

Eyeglass Assistance Request

Applicant Information