Plattsburgh Lions Club - Lions e-Clubhouse

To print an assistance form please click the link below.

English:

Spanish:

APPLICATION FOR 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 or

hearing related assistance. If you have private insurance, are receiving public assistance or

are personally able to pay, please do not use this application. Please mail the completed

application to P.O. Box 1031, Plattsburgh, N Y 12901; ATTN: Sight Chairperson

1. Name of person needing assistance: _________________________________________

2. If person needing assistance is under 18 years old, Name of representative & relationship:

____________________________________________________________

3. Address: ________________________________________________________________

4. Telephone: _______________________ E-mail:_______________________________________

5. Date of Birth: ______________________________

6. Type of assistance requested (please circle):

Eye exam Glasses Hearing Aid Surgical

7. Gross family monthly income: _____________ Source: _________________________

8. Total number of people in household: ________

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

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

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

12. How old are your present glasses: ______________________

13. 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: __________________