Meetings

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   Eau Claire Evening Lions

PO Box 791

Eau Claire, WI 54702-0791

 

Request for Lion’s Club Assistance

With eye glasses, hearing aids, and diabetic supplies

 

Name: ________________________

 

Address:  _____________________________________  Phone:  __________________

 

               ________________________________________________________________

 

Parent or Guardian:  _____________________________  Phone:  __________________

 

Occupation:  ____________________  Employer:  ______________________________

 

Monthly Income:  _______________  Health Insurance:  Y  N  Medical Assistance: Y  N

 

Monthly expenses (itemize):  _______________________________________________

______________________________________________________________________

______________________________________________________________________

 

Purpose and Reason for request: _____________________________________________

 

_______________________________________________________________________

 

________________________________________________________________________

Note: the above information will be kept confidential and only used for determining if assistance will be granted.  It is the sole responsibility of the  Club to determine how much or if any assistance will be granted.  Any finacial assitance will be paid to a medical supplier and not to an individual

 

I certify that the above information is true and accurate!

 

                                                                                    ______________________________

                                                                                    Signature                                 Date

 

                                                                                    ______________________________

                                                                                    Parent or Guardian                  Date

                                                                                    (Signature)

   Eau Claire Evening Lions

PO Box 8062

Eau Claire, WI 54702

 

Request for Lion’s Club Assistance

With eye glasses, hearing aids, and diabetic supplies

 

Name: ________________________

 

Address:  _____________________________________  Phone:  __________________

 

               ________________________________________________________________

 

Parent or Guardian:  _____________________________  Phone:  __________________

 

Occupation:  ____________________  Employer:  ______________________________

 

Monthly Income:  _______________  Health Insurance:  Y  N  Medical Assistance: Y  N

 

Monthly expenses (itemize):  _______________________________________________

______________________________________________________________________

______________________________________________________________________

 

Purpose and Reason for request: _____________________________________________

 

_______________________________________________________________________

 

________________________________________________________________________

Note: the above information will be kept confidential and only used for determining if assistance will be granted.  It is the sole responsibility of the  Club to determine how much or if any assistance will be granted.  Any finacial assitance will be paid to a medical supplier and not to an individual

 

I certify that the above information is true and accurate!

 

                                                                                    ______________________________

                                                                                    Signature                                 Date

 

                                                                                    ______________________________

                                                                                    Parent or Guardian                  Date

                                                                                    (Signature)

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