CONTACT US | Organization | North Dallas Shared Ministries

You must live in a zip code in Dallas County!

Meeting requirements does not Guarantee Assistance

EYEGLASS 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 just 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 - Do Not Type City, State or zip code in here.(Required)

Apt #

City - Do not type anything other than the name of the city you live in.(Required)

Zip Code(Required)

Telephone Number where you can be called(Required)

Type of phone:(Required)

Official Photo ID #(Required)

Sex (M/F):(Required)

Date of Birth(Required)

Age

Month(s)

Ethnicity:(Required)

Marital Status:(Required)

Email Address:(Required)

Enter Email Address Again:(Required)

PATIENT UNDER 18 YEARS OLD

Patients Name:- IF UNDER 18

Sex (M/F):

Date of Birth

Age

Month(s)

Household Information

Where do you live:(Required)

Apt/Condo/Motel name:(Required)

Apt Number

This field is hidden when viewing the form

today Date

Move-in Date(Required)

Time Lived at Residence:

Year(s)(Required)

YOU MUST FILL IN THIS FIELD

Month(s)

Landlord Name:(Required)

Phone:(Required)

EYEGLASS ASSISTANCE NEEDED

Brief explanation of why you need this help?(Required)

YOU MAY BE REQUIRED TO MAKE 2-3 VISITS TO NDSM. 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.

By submitting your mobile number, you agree to receive text messages from NDSM. You can opt-out anytime. Message and data rates may apply. Updated 8.8.2023.