Online Application for Eyeglass, Denture, & Hearing Aid Assistance by Kaw Nation | Jan 27, 2023 | Social Services Applications Today's Date *First Name *Last Name *Maiden NameStreet Address *Apartment, suite, etcCity *State *Enter State Abbreviation0 / 2Zip Code *Phone Number *Date of Birth *Kaw Roll Number *Currently Employed? *YesNoIf not, enter last date of employment.Last 4 Digits of Social Security Number *Number in Family *Student? *YesNoElder? *YesNoDiabetic? *YesNoDo you have a chart at Kaw Clinic? *SelectYesNoList Medicare, vision/dental insurance, state assistance, etc.Type of assistance requested: Please check all that apply./ Eyeglass Wear - ($400 approved every two years)/ Denture Work - ($500 approved every 3 years)/ Hearing Aid - ($1,000 approved every 5 years)Signature of applicant - Parent/Guardian must sign application for minors *Start signing your signature hereYour browser does not support e-Signature field.Submit Application
