Community Eye Care Day Application Children's Eyecare Day – 18 years and under – Friday, August 20, 2010 Patient’s Name * Parent's Name * Address * Phone number: * (Must live in Bay County) Last Eye Examination Date Location Do you currently have any glasses? Yes No How old? What Condition? Do you Wear Contact Lenses (Contact Lenses are not offered as part of this service) Yes No Employment Information (For Parent If Patient is Under 21) Current Employer How long? Previous Employer How long? Previous Employer How long? Insurance Information Do you have, or have you ever had, medical insurance of any kind? What and When? Do you have, or have you ever had, vision insurance of any kind? What and When? Do you have, or have you ever had, state assistance of any kind? What and When? Are you eligible for any insurance (medical, vision, or state assistance) that you have chosen not to sign up for? School Enrollment Name of School Program/Grade Level Expected Date of Graduation How is the child doing in school? Be specific. Family History of any Systemic Diseases: Family History of any Eye Conditions or Diseases: Medications: Have you ever been a patient of the Helen Nickless Clinic? Yes No Marital Status of Patient (if applicable): Pick one Married Single Divorced Widowed Do you Own or Rent your home? Pick one Own Rent How long at this address? Total Annual Family Income of everyone in household: (itemize and include source; also include SSI, child support, state assistance, alimony, food stamps, etc) Thank you for your interest — we'll contact you if you meet our criteria. *Confidentiality will be maintained but we reserve the right to verify accuracy. *Not all applicants will qualify. *Not all applicants who qualify will receive free eyewear; this will be at our discretion Security Code *