The Pokagon Fund Eye Grant Qualification Application

  • The New Buffalo Lions Club is pleased to administer The Pokagon Fund Children’s Vision Grant for Harbor Country residents. This grant will provide eye health and vision services to those children residing in the Fund’s geographic service area. Pre-qualification for the program is mandatory. Please complete all sections of the form below to assist us in your pre-qualification. For more information visit www.newbuffalolions.org, call 269-612-7602 or contact any New Buffalo Lions Club member.

    * required field

    Patient Information

    * Child’s Full Name:
    * Birth Date: (mm/dd/yyyy)
    * Age:
    * Gender:
    * Home Address:
    * City:
    * State:
    * Zip Code:
    Grade in School:
    School:
    * With whom does the child reside:
    If the child reside’s with someone other than those above, please specify:

    Parent/Guardian Information

    * Full Name of Parent/Guardian:
    * Relationship to Patient:
    * Phone:
    * Email:
    * Number of year’s at current residence:
        Same address as child?
    Home Address:
    City:
    State:
    Zip Code:

    Insurance Information

    * Do you have vision insurance?
    Yes  

    No
    * Do you have medical insurance?
    Yes  

    No
    If yes, who is your primary insurer?
    None

    VSP

    BCBS

    Medicare

    Other
    Name of other primary insurer?
    Who is your secondary insurer?
    None

    VSP

    BCBS

    Medicare

    Other
    Name of other secondary insurer?
    Name of policy holder:
    Relationship to patient:

    Previous Vision Care Information

    * Has your child ever had an eye examination?
    Yes  
    No
    If yes, date of last exam: 
    * Does child currently wear glasses?
    Yes  
    No
    If yes, since when: 
    *

        I understand that the above information is being provided to qualify my child in the Pokagon Vision Grant Fund and that completion of this form alone does NOT constitute eligibility.
    * Parent or Guardian’s Name as Signature:
    * Date Signed: (mm/dd/yyyy)
    TO QUALIFY YOU MUST ALSO SUBMIT PROOF OF RESIDENCY: COPY OF DRIVERS LICENSE, UTILITY BILL, TAX BILL OR LEASE. You may submit these documents in one of the following ways:

    • Give to a New Buffalo Lions Club Member
    • Mail to: PO Box 26, New Buffalo, MI 49117
    • Take to any Horizon Bank in New Buffalo or Three Oaks
    • Scan and email to us at info@newbuffalolions.org

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