Sight Conservation Application

Name *
Name
Date of Birth
Date of Birth
Address
Address
Home Phone
Home Phone
Cell Phone
Cell Phone
Eyeglasses Prescription Date
Eyeglasses Prescription Date
Has the Toccoa Lions Club provided glasses for you in the past?
Glasses are provided only once every 3 years.
Is this application for someone under 18 years old?
Has Applicant been diagnosed with diabetes?
Has Applicant been diagnosed with glaucoma?
Typing your name constitutes a legal signature

Must show proof of residency for at least 1 year. Choose ONE document.

  • Copy of first page of lease (rental) agreement.
  • Mortgage statement
  • Letter from home, shelter or transitional home stating that you live at that location. Must be on letterhead and signed by home/shelter employee.
  • Something that comes through the mail, with your name and address (ex. utility bill, bank statement, Social Security letter, library card)

Proof of Income: documents that show all household income

  • Last year's tax return
  • Last 2 months of bank statements
  • 3 current pay check stubs
  • Social Security Administration award letter
  • Food Stamp papers from DFACS
  • Letter from nursing home stating amount received for personal expenses
  • Unemployment Claim/Wage Inquiry statement