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Eau Claire Evening Lions

PO Box 791

Eau Claire, WI 54702-0791


Request for Lion’s Club Assistance

With eyeglasses, 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 financial assistance 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



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