HEAD START: EASY AS 1, 2, 3 . . .
Please help us identify students from your program to receive a Sight for Students award. Children who failed their vision screening but who, for financial reasons, were unable to secure proper follow-up diagnosis and prescription glasses, if needed, are prime candidates.
- The eligibility criteria
are:
- Family income is no more
than 200% of federal poverty level (see chart below)
- Child is not enrolled in
Medicaid or other vision insurance
- Child is 18 years old or
younger and has not graduated from high school
- Child or parent is U.S.
citizen or resident alien with a social security number
- Child has not used our program during the last 12 months
- Complete this form and
return it to us. Awards for services are made on a first come,
first served basis so please respond as soon as possible.
- Selected students will receive a Sight for Students award which provides an eye examination, prescription lenses and a covered frame at no cost, if prescribed.
Guidelines computed to 200% of poverty level
200% OF FEDERAL POVERTY GUIDELINES (1999) |
Size of family unit |
48 Contiguous States & D.C. |
Alaska |
Hawaii |
1
2
3
4
5
6
7
8
For each additional person add |
$ 16,480
22,120
27,760
33,400
39,040
44,680
50,320
55,960
5,640 |
$ 20,640
27,680
34,720
41,760
48,800
55,840
62,880
69,920
7,040 |
$ 18,980
25,460
31,940
38,420
44,900
51,380
57,860
64,340
6,480 |
Yes, we are interested in participating in Sight for Students and will abide by the eligibility criteria for the program in selecting students to be provided free eyecare services.
Date:
Contact Name:
Name of Organization:
Organization's Address:
City:
State:
Zip:
Signature of Contact:
Telephone Number:
Fax Number:
Number of Benefit Forms Requested for Needy Students
(Not to exceed 10% of the children enrolled in your program)
Please take a moment to ensure the information is correct and complete
Send form to:
Vision Service Plan
Attention Mary Kearney, M/S 411
P.O. Box 997100 Sacramento, CA 95899-9989
Fax: (916) 858-5388
Thank you for participating in Sight for Students!
If you have questions about the Sight for Students program, please contact Mary Kearney at Vision Service Plan, 1-800-852-7600, Ext. 5156.
