Request for Eyeglass & Hearing Aid Assistance
Please fill out the form below in its entirety . Your signature certifies the accuracy of this information and authorizes the Westville Lions Club to verify certain details of your income, assets, state and federal benefits. Please allow two weeks for a reply from us while we check.
Our assistance may only include referring you to a public aid provider or agency or providing transportation if you qualify. Any assistance we authorize will be through providers of our choice. Any eyeglasses we authorize will be functional - you must pay for any features not deemed medically necessary (such as graduated bifocals, fashion frames, tints and special lenses). The information you provide is confidential and will be used only to verify your financial statement. In most cases, a co-payment will be required from you upon services.
The following information concerns the person needing eye care. If he/she is a minor (under 18), a parent or guardian income must be used in this form. If you have any questions, please contact us.