Application for Hearing Services

Application for Hearing Services
Applicant: Complete Sections 1 and 2 and submit this application along with any requested documentation to the Lions Club listed in Section 3. You will be notified of your application status by the Lions Club Volunteer.

Applications are generally processed within several weeks but are dependent on staff and volunteer availability. Your patience with this volunteer driven effort is appreciated.

PLEASE NOTE: THERE MAY BE SERVICE FEES INCLUDED WITH THIS PROGRAM. PLEASE ASK YOUR LIONS CLUB.

Section 1: Applicant Information
Request for assistance with:

Hearing TestHearing Aid(s) Only (I have a current hearing test/audiogram)
Name

Applicant First NameApplicant Last Name
Applicant Date of Birth

MonthDayYear
Home Address (if houseless, where do you usually reside)

Home Address (if houseless, where do you usually reside)

Mailing Address if different

CityState

Zip Code
Preferred Name if different than first
preferred name if different than given first
County
County
Primary Phone Number
Primary Phone Number
Secondary Phone Number
Alternative Phone number
COUNTY
County
Email Address
example@example.com
Number of People in Household?
Number of People in the household
Occupation
Occupation
Preferred Written or Spoken Language(s)
Preferred written or spoken language
Who Can We Call With Questions?

YourselfOther
If Other please include Name:
Name
Phone Number
Please enter a valid phone number.
Relationship to You:
Relationship to You
PLEASE NOTE: YOUR APPLICATION WILL NOT BE REVIEWED UNLESS PROOF OF INCOME IS INCLUDED.

Proof of income may be: pay stubs from the last 2 recent pay periods, current DHS/TANF/SSI/Disability award letter, food stamp benefit letter, or awards letters from other government or state assistance programs.
File Upload

Please upload proof of income here for processing. If you are not able to upload, please mail a copy of the proof of income to Coos Bay Lions ROAR program, PO Box 3, Coos Bay OR 97420
Cancelof
MONTHLY GROSS INCOME

Before Taxes and Deductions
Applicant Wages
Applicant Wages
Spouse/Domestic Partner's Wages
Spouse/Domestic Partner's Wages
Welfare Benefits
Welfare Benefits
Social Security/Disability
SSI/SSD
Food Stamps
Food Stamps
Other
Other Income
Total Monthly Income
Total Monthly Income
Do you have Hearing Insurance?

YesNo
If Yes, please explain why you are requesting help from the Lions?
When was your last hearing exam/test?
When was your last hearing exam/test?
Name of Provider/Clinic
Section 2: Authorization for Release of Information
By signing below, I authorize the Lions Club listed in Section 4, the Oregon Lions Sight & Hearing Foundation, and their qualified partners to receive my financial and hearing related medical information. I understand that I may revoke this authorization in writing at any time by sending a signed and dated written statement, except to the extent that the organization(s) named above may have acted in reliance on this authorization. I have had the opportunity to read and consider the contents of this authorization.
Applicant or Guardian Signature

Clear
Date

MonthDayYear
Section 3: Club Contact Information
Coos Bay Lions Club

PO Box 3

Coos Bay, OR 97420

541.297.4474
Should be Empty:

Application for Hearing Services

MONTHLY GROSS INCOME

Section 2: Authorization for Release of Information

Section 3: Club Contact Information