Do you need financial help with securing eyeglasses or an eye exam? Are you a resident of Hanover? Fill out the following application, send it to us, and we will let you know how we can help.
HANOVER LIONS CLUB EYEGLASS AID REQUEST FORM
The Hanover Lions Club assists in providing glasses for Hanover residents who are not covered by
insurance or some other programs and are without means themselves. Our Lions Club also tries to
serve residents of surrounding communities who do not have a local Lions Club.
In connection with your inquiry, we respectfully ask that you fill out and return this form to:
Hanover Lions Club
Sight and Hearing Committee
PO Box 871
Hanover, NH 03755
Email: firstname.lastname@example.org Fax: 603-653-8267
Applicant’s name: __________________________________________________ Age: _______________
Address: __________________________________________________________Phone: _____________
Employer’s name and address: ___________________________________________________________
How long employed? ______________
Spouse’s employer and address, if applicable: _______________________________________________
Number of dependents: _____________
What type of health insurance do you have? ________________________________________________
Who referred you to us? ________________________________________________________________
We typically provide a Budget Eyeglass Package provided by cooperating vendors. This package may
include either an eye exam and glasses, or only glasses, depending on your need. The vendors which we
currently have cooperative arrangements are:
North Country Optical, for eye exams and glasses; Pro-Optical, for glasses only
If you use a different vendor, we may provide a voucher in the amount we would provide for a Basic
Package from our cooperating vendors, only, and the recipient must make up any difference in price.
Requests for needs over and beyond the Basic Package may be considered on special request.
Please wait to hear from us prior to making your appointment.
We have many requests for help, and would like to provide assistance to as many people as possible,
but, have limited funds available. Could you or anyone in your family contribute anything towards the
cost of your glasses? ______. If “Yes”, how much might you/they be able to provide? __________.
In the space below and on the back, if necessary, please provide any additional information that might
assist us in confirming your need for financial assistance. Please be assured that any information
provided will be kept confidential.