LIONS OF VIRGINIA
Application for Hearing Aid Assistance
Date: ________________
Applicant's Name:_________________________________________________________________________________
Applicant's
Address:_______________________________________________________________________________
(Street or Route) (City or Town) (Zip)
Age: __________ Sex: __________ Telephone: ( )______________
NOTE: If applicant is a minor or a student, the parent or person
responsible for him/her must complete the following:
School now attending:
_____________________________________________________________________________
Name of Parent or Person making application:
__________________________________________________________
Address:
________________________________________________________________________________________
(Street or Route) (City or Town) (Zip)
Do you rent your home? _______ If so, amount of rent? $______________
Do you own your home? _______ If so, amount of house payment? $____________
What is your present employment? _______________________________________________
How long? __________
What was your past employment? _______________________________________________
How long? __________
What is your present income? $__________________ Total family income?
$_______________
Number in family who are dependent on the above income? _________________
Is family on welfare assistance? _________ If so, what amount?
$_________________
Do you have Medicaid? ___________
Have you ever received assistance from the Lions Club? __________
If so, when and for what reason(s)?___________
________________________________________________________________________________________________
Present request for assistance is for:
Hearing Aid(s): __________
Surgery: __________
Medical Treatment: __________
Signature of Applicant:
__________________________________________________________
Signature of person making application:
_____________________________________________
(Only if applicant is dependent)
CERTIFICATION:
This is to certify that the above case has been fully investigated and
it is determined that financial assistance is needed and is not available from
any other source.
Health Department or
Name: _______________________________________
Referral Agency:_________________________________
Address: _____________________________________
Phone:_________________________________________
_____________________________________________
Additional Comments:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
------------------------------------------------------------------------------------------------------------------
APPLICATION APPROVED: __________ FOR: $_____________
LIONS CLUB: ___________________________
APPLICATION NOT APPROVED: _________ If not, for what reason(s)?_________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________