East Texas Lighthouse |

Application for Services The Lighthouse understands the challenges that blind and visually impaired individuals face in everyday life. The objective of Client Services is to remove barriers and allow individuals to become independent, productive citizens of their community. Our staff strives to meet each client where they are to empower and help them obtain their personal goals. Please allow 5-7 business days for the application to process. We look forward to meeting you soon! Date of Application:
First Name*
Middle Name:
Last Name*
Phone*
Email Address:*
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City
State/Province
Zip
Date of Birth:
Emergency Contact Name:
Emergency Contact Phone Number:
Eye Physician Name:
Lead Source*
Please let us know how we can help.*

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