Complete the Following:

Name _________________________________________________

Parent/Guardian/Spouse __________________________________

Address _______________________________________________

Age _________________ Telephone ________________________

I need help with: (check all that apply) Exam_____ Lenses _____ Frames _____

Lions help is needed because (income, expenses, health, family etc.) Explain below:

I certify that all the above information is correct and accurate.

Signed _________________________________ Date _________________
           ..........................................................................................................................
         Take this form to a minister, DCFS, public health or school official (must be non-related)

I certify from personal knowledge that ______________________ has serious need for both vision care and financial assistance. My certification is based upon my involvement with the individual or the family.

Signed ___________________________ Position ______________________

Address ____________________________________Phone ______________

PRINT & RETURN TO: Macomb Lions Club, Sight/Hearing Committee, PO Box 1, Macomb, IL 61455

Updated 8/5/08 jeg