Application Form | Anchorage Area Lions Joint Sight Committee

“That Others May See”

Anchorage Area Lions Joint Sight Committee
P O Box 612
Girdwood, AK 99587
.

This form is to be completed by the sponsor. It is the responsibility of the sponsor to assure that the information is both complete and correct.

Please print.

APPLICANT INFORMATION

Full Name

Age

Mailing Address

Phone

Email

Parent/Guardian

SPONSOR INFORMATION

Full Name- Contact

Sponsoring Organization

Mailing Address

Phone - Home

Phone - Cell

Phone - Work

Email

EMPLOYMENT INFORMATION OF APPLICANT OR GUARDIAN IF REQUEST IS FOR A CHILD

Status of Employment

Gross Monthly Income

Current Employer

Previous Employer

Reason for Request

EYE CARE INFORMATION:

Insurance Information - yes or no

Denali KidCare: YesNo
Medicaid: YesNo
Private: YesNo
Is applicant an Alaskan Native

Is a new prescription available

Date of previous prescription

Date of last exam:

Where:

When:

Date of previous request to Lions

Where:

When:

What is needed for applicant

OTHER SOURCES OF INCOME IN HOUSEHOLD

Add more

Applicant or Guardian's Signature

I have personally interviewed the applicant and verify the information is accurate:

Sponsor's Signature

Date

The decision regarding the assistance will be sent to the sponsor. If more space is needed for more information, attach a separate sheet. Forms not containing the information requested will be returned. The Joint Sight Committee has been assisting residents in Anchorage and Girdwood since the
late 1960s. The committee’s purpose is to provide financial assistance to Anchorage Area residents with a financial need associated with sight. The committee operates as a last resort resource for clients who need financial assistance and have NO OTHER MEANS – NO INSURANCE OF ANY KIND.

Return the completed application to the committee for review. Applications are accepted by USPS mail to Box 612, Girdwood, AK 99587 or by email to anchoragejointsight@gmail.com.

Leave a message on our voicemail if there are questions. Voicemail phone# 907-783-0171