Sight for All United Offie# 330-750-1867
966 Fifth Street sightforallluann@gmail.com
Struthers, OH 443471 sightforallunited@gmail.com

Referred By: *

Applicant Information

First Name *

Middle Initial

Last Name *

Social Security Number

Current Address

City

State

Zip

Birthdate

Age

Marital Status

Day Phone

Night Phone

Work Phone

Cell Phone

Email Address

Living Situation (Alone - Family)

How Many in household?

Other Contact Name

Relationship

Other Contact Phone Number

Responsible Party if Applicant is a Dependent

First Name

Last Name

Social Security Number

Email Address

Day Phone

Night Phone

Work Phone

Cell Phone

Current Address

City

State

Zip

Relationship to Applicant

Monthly Income Please enter 0.00 if category does not apply

Primary Income Source

Primary Income

Secondary Income Source

Secondary Income

Other Income Source

Other Income Amount

Other Income Source 2

Other Income Amount 2

Total Income:

0.00

Monthly Expense Please enter 0.00 if category does not apply

Monthly Expenses

Monthly Amount

Monthly Expenses

Monthly Amount

Monthly Expenses

Monthly Amount

Monthly Expenses

Monthly Amount

Monthly Expenses

Monthly Amount

Monthly Expenses

Monthly Amount

Monthly Expenses

Monthly Amount

Monthly Expenses

Monthly Amount

Monthly Expenses

Monthly Amount

Total Expenses:

0.00

Income Documentation

Please forward income doucmentation to:

Sight for All United
966 Fifth Street
Struthers, OH 443471


or email at sightforallluann@gmail.com

Please select all the apply for income verification *

Government Benefits

Are you on SSI Benefits? *

If so, which porgrams

Have you every applied for SSI benefit(s) *

Are you disabled *

Have you ever served in the military *

Are you a Veteran *

Health Insurance

Health Insurance Provider

Policy or Group Number

Address of Provider

Phone Number of Provider

Eye Diagnosis

Explain Eye Condition

Other Information

In consideration of yor acceptance of this application form, I hereby for myself, my administrators, my heirs and assigns, waive and release all rights and claims for damages I have against the organizers of this event, their associates and representatives. Completion of the application does not guarantee assistance. I certify that the above financial information is correct to the best of my knowledge, I hereby authorize Sight for All to obtain all information concerning my health insurance.

Date of Signed Release

Patient or Guardian Signature

clear

I agree and give permission that my name, photo and assistance I receive can be published and distributed to help benefit others looking for assistance.

Date of signed Picture Release

Patient or Guardian Picture Release

clear