Need Assistance? We can help.
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
(Signature)
