APPLICATION FOR INDIVIDUAL ASSISTANCE

Date:_____________ Emergency:______________ Routine:___________

Applicant Name: First______________ Middle_______ Last____________________________

Address: Street__________________ City__________________ State_______ Zip__________

Date of Birth:_________________ Soc.Sec.#:_________________ Phone #:________________

Place of Employment:____________________________ Total Monthly Income:_____________


FOR PARENT OF GUARDIAN OF MINORS

Father’s Name:_______________________________________ Soc.Sec.#:_________________

Place of Employment:____________________________ Total Monthly Income:_____________

Mother’s Name:______________________________________ Soc.Sec.#:_________________

Place of Employment:____________________________ Total Monthly Income:_____________

HOMEOWNER: YES___ NO___ MONTHLY PAYMENT/RENT:$________________

REASONS FOR NEED AND/OR ADDITIONAL COMMENTS:




I understand that my signature gives my consent for the Lion’s Club to verify the above information. If approved, payment will be made directly to the doctor. I further understand that I am responsible to make arrangements with the doctor for the balance of fees for medical services.

APPLICANT’S SIGNATURE_____________________________________________________

DOCTOR’S NAME______________________________________ Phone #:________________

Address: Street__________________ City__________________ State_______ Zip__________

Explain the disease or injury:______________________________________________________

Treatment recommended by doctor:_________________________________________________

_______________________________________ Estimated Cost of Treatment_______________

OPTOMETRIST’S SIGNATURE___________________________________________________
The Alliance Lion’s Club requires approval of application before services are performed.

FOR CLUB USE ONLY:


Committee Recommendation:

Yes_____ Amount $____________


No_____ Reason





Signature of Chairman:


Signature of Co-Chairman:




Club Approval:

Yes_____ Amount $____________


No_____ Reason






President’s Signature:


Date of Approval:__________________ Date Paid:___________________

Form Updated 1/1/2003 Page #