icareUSA.org :: Application Online

Please complete all requested information to the best of your ability and then Click on the SUBMIT button at the bottom of the form.

Lions Club Member or Organization Who Referred You: *
Date: *
Name: *
Age:
Address:
City:
ZIP Code:
Phone Number: *
How long have you lived in Denver County?
Number in Family Living at Home:
Ages:
Financial Resources: (Check All that Apply) *	Veteran? Medicaid? Medicare? Other Insurance?
Total Yearly Income:
Source of Income:	SSI SSDI ADC TANIF
Are You Employed?	Yes No
If Employed, Income from Job:
If Employed, How long at Job?
Do you receive Food Stamps?	Yes No
Monthly Food Stamps $ Amount?
How long have you been receiving Food Stamps?
Do you Rent or Own your home?	Rent Own
How much is your monthly Rent or Mortgage Payment?
Do you have a car?	Yes No
If you have a car, what is your monthly Payment?
Age of car?
Do you have a checking account?	Yes No
Do you have a Savings Account?	Yes No
What kind of assistance are you seeking?
Have you ever received assistance from the Lions Club before?	Yes No
If you have received assistance before, what kind and when?
When did you have your last eye examination?
Name and Address of Eye Doctor: