APPLETON NOON LIONS CLUB MONDAY NOON GRAND MERIDIAN P. O. BOX 762, APPLETON, WISCONSIN 54912 WWW.APPLETONNOONLIONS.COM APPLETONNOONLIONS@TPONET.COM

1. Full Name of Recipient needing services: __________________________ Age:_____
   Address: ___________________________________________________
   Email address: ______________________________________
   Phone number: _________________
   Family Members (by age): ____________________ ____________________

2. What is your need? Explain in as much detail as possible.
   Visual________________________________________________________
   Hearing_______________________________________________________
   Other_________________________________________________________

3. What is your family's economic circumstances?
   Employment (all parties)___________________________________________
   Insurance coverage_______________________________________________
   Partial Payment__________________________________________________
   Social Security Eligibility___________________________________________

4. Are you working with any social service or other agency,
   i.e. Division of Vocational Rehab, etc.? _______________________________

5. Were other requests sent, i.e. to other Lions' Clubs or
   to other benevolent associations? ____________________________________

6. What is the actual cost of the request (less any discount possible)?__________

7. Have you considered leasing of equipment?___________________________

8. Have you considered purchase over time? ____________________________

Note on the back of the form any other information as you see fit.

Please return to the address above. We will be in contact with you as soon as possible.
--Appleton Noon Lion's Club Thank you!

Form submitted by:
      Name_____________________ Title___________ Phone no._________________

10/09