Located at Goodwill
2747 Belmont Avenue
Youngstown OH 44505
330-779-8045

Applicant Information

Responsible Party if Applicant is a Dependent

Monthly Income Please enter 0.00 if category does not apply

Total Income:
0.00

Monthly Expense Please enter 0.00 if category does not apply

Total Expenses:
0.00

Income Documentation

Please forward income doucmentation to:
 
Sight for All 
2747 Belmont Ave.
Youngstown OH 44505

or email at sightforalldom@gmail.com
Please select all the apply for income verification *

Government Benefits

Health Insurance

Eye Diagnosis

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. 
Patient or Guardian Signature
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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. 
Patient or Guardian Picture Release
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