Hearing Aid Application

Todays Date

MonthDayYear
Hearing Aid Application

Please understand that by completing this form you are NOT guaranteed in any way that you will receive assistance or benefits from the Horn Lake Lions Club or any of their affiliates. Horn Lake Lions Club will contact you to advise whether or not you have not been selected to receive assistance. If you are selected you will be required to supply your own transportation to and from the eye clinics. Horn Lake Lions Club will work directly with the eye clinics on all financial obligations. Only one person per household can receive assistance per calendar year.
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Patient Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Phone*

Area CodePhone Number
Work Phone

Area CodePhone Number
Patient E-Mail*
Emergency Contact*
Relationship to Patient*
Emergency Contact Phone Number*

Area CodePhone Number
When was your hearing test?*
Doctor's Name:
Do you currently wear hearing aids?*

YesNo
Have you been assisted by Lions Club previously?*
When?
Club name:
Health insurance available for the patient:*

NoneMedicareMedicaidSSI/DisabilityFamily AssistanceOther
Are you employed:*
Employers Name and Address:
How long on the job:
Total Monthly Household Income:*
Number of Adults in Household:*
Number of Children in Household:*
House payment/Rent*
Groceries*
Electricity:*
Gas:*
Medicine:*
Car Payment:*
Other Monthly Bills:*
Is patient a minor?*

YesNo
Guardian's Name:
Address of person filling out form (if different than patient):

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number (if different than patient):

Area CodePhone Number
Signature*

Clear
By signing you agree to the conditions stated above and that the information included in this form is accurate to the best of your knowledge. If preferred the form maybe be printed below and mailed to Horn Lake Lions Club, PO Box 642, Horn Lake, MS 38637.
Should be Empty: