Assistance Application

Please fill out the application below to apply for assistance with vision issues.

Our Vision Outreach Director will contact you within 5 business days to schedule an appointment. You will be responsible for your own transportation and must be on time to avoid scheduling conflicts. Contact our office 24 hours in advance to cancel or reschedule your appointment, missed appointments may not be rescheduled and may further disqualify you from receiving assistance through Friends for Sight.

Eligibility Requirements:

Have an income below established guidelines based on household size (at or below 200% of the federal poverty guideline)
Have not received services through Friends for Sight in the past 12 months

Your name *

Phone *

Email address *

Home address *

Date of Birth *

We will try to accommodate your date as best as we can, if you need more than one day please note in additional information.

Services Needed *

Screening (this is not an eye exam)

Eye Exam & Glasses

Glasses only

Have you received services through Friends for Sight in the past? *

YES

Do you have private or government insurance including Medicaid/Medicare? *

YES

Have you received an eye exam in the past 12 months? *

YES

Number of people living in your household? *

Monthly Household Income *

Additional information *

Glasses Prescription

Drag and drop files here or Browse

If you only need help with glasses attach a copy of your current prescription.

First Name