Request For Assistance

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If you are need of vision or hearing care and cannot afford such, please fill out the following request for assistance and a club representative will contact you as soon as possible. If you have any questions, then please e-mail ForsythCountyLions@gmail.com.

NOTE: All requests are kept in strictest confidence and are subject to approval.

Please DO NOT provide any personal account information, including but not limited to Social Security Number, insurance card information, credit card number(s), and bank account number(s). The Forsyth County Lions Club will NEVER ask you or your representative(s) to provide such information.

Name of Person Requesting Assistance
*

Relation to person requesting assistance
*

Self

Immediate Family Member (including step-parents, step-siblings, and step-children)

Other (e.g., caseworker)

If you answered other than "Self", please explain your relationship to the individual requesting assistance and include your point-of-contact information.

Street Address *

City/State/Zip *

Phone Number *

E-mail Address *

Reason For Request *

Vision (Eyeglasses and/or Eye Exam)

Hearing (Hearing Exam)

Required

Is the person needing assistance a resident of Forsyth County, Georgia?
*

Yes

Is the person needing assistance 18 years-of-age or older? *

Yes

Does the person needing assistance have insurance coverage (including but not limited to Medicaid or Medicare)?
*

Yes

What is the primary income source of the person needing assistance? *

What form(s) of assistance does the person needing assistance currently receive?
*

Medicaid (NOTE: Please check Medicaid plan for vision coverage.)

WIC Vouchers

Temporary Assistance for Needy Families (Food Stamps)

Social Security

Rent and/or Utility Assistance

Food

Required

I acknowledge that that all my answers to the questions above are correct to the best of my knowledge.

I also acknowledge that I will be interviewed by the Forsyth County Lions Club’s Sight, Hearing, and Family Services (SHFS) coordinator, my application will be either approved or denied based on said interview, and that the SHFS coordinator’s decision to approve or deny will be final.

If my application is approved, I acknowledge that I will be responsible for following instructions as per a letter that will be sent to me by the SHFS coordinator, including (but not limited to) making and keeping an appointment with said provider, giving a copy of my approval letter to said provider on the day of the appointment, and making my own travel arrangements to and from the office of said provider.

PLEASE CHECK HERE

Required

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