Sight for All United               Offie# 330-750-1867
966 5th Street                       Fax# 330-750-1562
Struthers, OH 443471          Cell# 330-307-3962

Applicant Information

Responsible Party if Applicant is a Dependent

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Total Income:

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Income Documentation

Please forward income doucmentation to:
Sight for All United               
966 5th Street                      
Struthers, OH 443471          

or email at
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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. 
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