Eyesight/Hearing Assistance

The Burley Lions Club provides financial assistance for glasses and hearing aids to qualifying community members.

Applicant Information

Full Name *

Sex

Age

Address *

City *

State *

ZIP *

Home Phone

Message Phone

Total Monthly Income

Utilities

Food

Phone

Gas

Rent

Auto Insurance

Prescriptions

Cable TV

Miscellaneous

Family Members in Household

County of Residence

Years in County

Referred by

Reason for Applying *

Family Physician

Family Eye Doctor

I certify that the information provided is true and complete to the best of my knowledge. *

Date *