Application for Assistance

Applicant:

Name: _________________________________________ Date: ___________

Address: _________________________________________________________

Phone: ____________________________ Occupation: __________________

The above named applicant authorizes the Rockdale Lions Club to administer
assistance and fully understands that in no way does the Rockdale Lions Club,
Lions of Illinois Foundation or Lions International assume any responsibility
or liability for any or all services or treatments rendered.

Applicant’s Signature: __________________________________________

Referred by:

Name: ___________________________________ Title: __________________

Address: ______________________________________ Phone: ____________

Description of Needs: ______________________________________________

Signature: ______________________________________________________

Services Rendered by:

Name: __________________________________________________________

Address: ________________________________________________________

Phone: _______________________ ID or SS#: ________________________

Signature: ______________________________________________________

Lions Club Authorization by: __________________________________________

Amount of Assistance: $___________

Please return this application to the Rockdale Lions Club, 48 Meadow Ave, Rockdale, IL 60436