Lexington Park Lions Club Vision Assistance Request Form

The Lexington Park Lions Club offers financial assistance to residents of the Lexington Park area who are unable to afford vision exams and/or eyeglasses. Eligibility is based on household income, which must be less than twice the Federal Poverty Level (FPL), as defined by current federal guidelines. Please be advised that if you have health insurance that covers vision care, you may not qualify for assistance through this program.

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Name

My family income is less than twice the Federal Poverty Level (FPL)

No Yes

Address

Email

Phone Number

Please note: Completion of this form does not constitute authorization or guarantee of financial assistance. All applications will be reviewed in accordance with established eligibility criteria, and support will be provided based on available resources and demonstrated need.

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