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Click on the link below to download or print an assistance application.

http://e-clubhouse.org/userfiles/22643/file/Sight%20Application.pdf

APPLICATION FOR DIABETES, SIGHT OR HEARING ASSISTANCE

Plattsburgh Lions Club

P.O. Box 1031

Plattsburgh, N Y 12901

It is the desire of the Plattsburgh Lions Club to serve those individuals who need sight,

hearing or diabetes related assistance. Please mail the completed application to P.O. Box

1031, Plattsburgh, N Y 12901; ATTN: Sight Chairperson

1. Name of person needing assistance: __________________________________________

2. Address: ________________________________________________________________

3. Telephone: ______________________________

4. Date of Birth: ______________________________

5. Type of assistance requested (please circle):

Diabetes Eye exam Glasses Hearing Aid Surgical

6. Gross family monthly income: _____________ Source: _________________________

7. Total number of people in household: ________

8. State your preference for Doctor for eye/hearing exam: __________________________

9. State where you would prefer to purchase glasses:_______________________________

10. Date of last eye or hearing aid exam: ______________________

11. How old are your present glasses: ______________________

12. Other pertinent information: ________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Assistance is given without any conditions, however, if your financial situation changes,

would you be willing to contribute to the Lions Club so we may help others?

Yes No

I authorize the Plattsburgh Lions Club to investigate all statements made on this application.

I understand that assistance will be limited to the current resources of the club.

Signature: _________________________________ Date: _____________________

Address: ____________________________________________________________

Telephone: ________________________________

Our Motto:

Join the fight to save sight

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