I hereby authorize any government or private organization or persons who may have current access to my financial records or medical history to release said records and history to the Rolla Lions Club for express purpose of determining my eligibility for the assistance I am requesting.

For Minors: This is to authorize up to and not exceed ninety dollars ($90) for an exam, lenses and frames for a student under eighteen (18) years of age. The sight program will pay for glass lenses and a select group of plastic frames only.

Additional cost exceeding the ninety-dollar amount such as: tinted lenses and metal frames, will need to be provided by Parent/Legal Guardian.

This program is not intended for a yearly maintenance program for eye care.

*Individual cases will be handled on special needs basis.

Thank you for your service, interest and consideration – and most of all, your fine-cooperation with the ROLLA LIONS CLUB SIGHT CONSERVATION COMMITTEE.

Note to Applicant: Normally a two (2) year interval between services is required. Applicants MUST make their own appointment with InVision Eye Care or Dr. Falkenhain.