California Vision Project (Cvp) Application Form
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1CALIFORNIA VISION PROJECT (CVP) APPLICATION FORM
The California Vision Project provides free eye exams to eligible low-income families.
Services are donated by volunteer optometrists throughout California.
Eligibility requirements: All eligibility requirements must be met in order to qualify (PLEASE READ)
The person(s) seeking an eye exam must have no public or private insurance that covers eye exams;
Applicants must not have had an eye exam in the last 2 years;
Applicants are low-income and are unable to pay for eye care
;
(income guidelines listed at )
$10.00 non-refundable administrative fee (per person) must accompany the application.
Cash
Money Orders
or
can be made payable to “The California Vision Foundation”
Home address: (
Please print)
______
______
State
Zip
Address___________________________________________
(
) ______-_________
Daytime telephone number
________________________________
Apt. #_____
_____________________________________
City
Please answer all questions below. Verification may be requested.
1. Is anyone in your household currently employed (full-time or part-time)?
Yes
No
2. What was your household’s approximate gross annual income before taxes and deductions? _____________
3. What is the total number of people in your household living with you, including yourself? _____________
4. How far are you able to travel for your appointment? _________________________________________ miles
Please list any particular cities that you would be able to travel to for your appointment:
_____________________________________________________________________________________________________
List all family members who are applying for a free eye exam:
Does this person have
Has this person had an
any private or
Name
Date of Birth
eye exam in the last
government insurance
two years?
that covers eye exams?
1.
/
/
Yes
No
Yes
No
2.
/
/
Yes
No
Yes
No
3.
/
/
Yes
No
Yes
No
4.
/
/
Yes
No
Yes
No
Your completed form will be reviewed to determine your eligibility. Verification of income may be requested. Eligible
patients will be notified by mail and will receive a complete eye exam without cost if a volunteer is available in your
area.
Mail this completed application with the $10.00 (Cash or Money Order) Administrative Fee(s)
to:
California Vision Foundation
2415 K Street, Sacramento, CA 95816
If you have any questions please contact Amanda Winans or Sarah Harbin at (800) 877-5738.
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