Skip to content
Introducing Now-Forward, formerly North Dallas Shared Ministries!
Para Español, toca aquí:
Español
Toggle Navigation
Our Services
Food
Clothing
Vision
Medical
Dental
Counseling
ESL Classes
School Uniforms & Supplies
Tax Preparation
Rent & Utility Assistance
Get Involved
Donate
Volunteer
Partner
About Us
Mission & History
Leadership
Financials
Service Areas
Digital Media
Guide to Emergency Assistance
Contact Us
GIVE
Apply for Vision Assistance
Atomic Dev
2025-01-15T16:23:32-06:00
Apply For Vision Assistance
Need help with vision care? Fill out the form below to apply for assistance and take a step toward clearer sight.
Fill out the form to apply:
Step
1
of
5
20%
I read the requirements, meet the initial requirements, and understand that just completing the application does not guarantee approval for assistance.
(Required)
Yes
EYEGLASSES APPLICATION
MUST BE FILLED OUT BY ADULT OVER 18 - IF SEEKING ASSISTANCE FOR A CHILD, THEIR NAME AND AGE CAN BE TYPED IN BELOW IN SECTION "PATIENT UNDER 18 YEARS OLD"
If more than one person in household needs a pre-screening and they are over 18, you can list them in the "Brief explanations" section at bottom of application.
THIS MUST BE COMPLETED BY HEAD OF HOUSEHOLD - 18 AND OVER
(Required)
First
Middle
Last
Street Address
(Required)
Do Not Type City, State or zip code in here.
Apt #
City
(Required)
Do not type anything other than the name of the city you live in.
Zip Code
(Required)
Telephone Number
(Required)
Re-Enter Telephone Number
(Required)
Email Address:
(Required)
Re-Enter Email Address:
(Required)
Official Photo ID #
(Required)
Sex (M/F):
(Required)
Select One
Male
Female
Date of Birth
(Required)
MM slash DD slash YYYY
Age
Auto Calculates
Ethnicity:
(Required)
Select One
White
Bi-Racial
Black
Hispanic
Asian
Other
Marital Status:
(Required)
Select
Single
Living Together
Married
Divorced
Widowed
Other
PATIENT UNDER 18 YEARS OLD
Patients Name:- IF UNDER 18
First
Middle Name
Last Name
Sex (M/F):
Select One
Male
Female
Date of Birth
MM slash DD slash YYYY
Age
Auto Calculates
Household Information
Where do you live:
(Required)
Select
Apartment
Condo
House
Duplex
Motel
Shelter
Trailer
Other
Apt/Condo/Motel name:
(Required)
Apt Number
This field is hidden when viewing the form
Today Date
MM slash DD slash YYYY
Move-in Date
(Required)
MM slash DD slash YYYY
Time Lived at Residence:
Year(s)
(Required)
Months
Landlord Name:
(Required)
Landlord's Phone Number:
(Required)
Re-Enter Landlord's Phone Number:
(Required)
EYEGLASSES ASSISTANCE NEEDED
Brief explanation of why you need this help?
(Required)
YOU MAY BE REQUIRED TO MAKE 2-3 VISITS TO NOW FORWARD. 1 - FOR PRE-SCREENING TO SEE IF YOU NEED A PRESCRIPTION AND/OR READERS. 2 - FOR ACTUAL VISIT TO GET PRESCRIPTION IF NEEDED. 3-TO PICK UP YOUR EYEGLASSES WITH PRESCRIPTION.
A RESPONSE WILL BE EMAILED TO YOU WITHIN 2-4 DAYS ONCE YOU SUBMIT.
PLEASE READ SCREEN AFTER YOU CLICK SUBMIT FOR IMPORTANT DIRECTIONS.
Phone
This field is for validation purposes and should be left unchanged.
Page load link
Go to Top
