North Dallas Shared Ministries

Application for Visual Assistance







    

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Additional Adults Age 18 or Over Living in Your Household that need Vision Screening:



Name First/Last                                 Sex M/F           Date of Birth     Relationship to you       Social Security #Use dashes (-) 123-45-6789
    
    
    
    

Children Under Age 18 Living In Your Household that need Vision Screening


  
Name First/Last                               Sex M/F             Date of Birth     Relationship to you       Social Security #Use dashes (-) 123-45-6789