Humanitarian Assistance LCF-II PhoneThis field is for validation purposes and should be left unchanged.Date of Application MM slash DD slash YYYY Type of Assistance Requested(Required) Project Assistance Equipment Assistance Other Describe the Assistance Requested PurposeIf available, upload a PDF supporting document.Accepted file types: pdf, Max. file size: 32 MB. Only one PDF document under 100MB can be uploaded.Amount Requested from LCFClub Contribution AmountOther Contribution AmountTotalAuto-Calculated ValueEquipment and FundingIs this a Zone request? Yes No List Participating ClubsHow many SPOTS / Hearing Screening devices are currently in your zone?How many joint screenings in the past 24 months?Upload vendor quoteAccepted file types: pdf, Max. file size: 32 MB. Only one PDF document under 100MB can be uploaded.Type of Equipment Vision Hearing Other Check all that applyManufacturerTotal Cost of EquipmentEquipment DescriptionAmount Requested from LCFSupporting Fund Source 1 NameSupporting Fund Souce 1 AmountSupporting Fund Source 2 NameSupporting Fund Souce 2 AmountSupporting Fund Source 3 NameSupporting Fund Souce 3 AmountTotal Supporting Fund SourcesAuto-Calculated ValueStatement of Need(Required) Replacement equipment to maintain current screening services New equipment request to expand screening services Original Date of Purchase MM slash DD slash YYYY Describe how the Club or Zone will use the device to expand services.How many screenings has your Lions Club sponsored over the past 24 months?How many children has your club screened over the past 24 months?Does your Club submit all screening reports to the District Children Services Chair? Yes No Does your Club currently own SPOT Audiometer Both None of the above Current equipment ageDoes your Public School Division allow you to screen children in the schools? Yes No Club Information & AcknowledgementClub Requesting Humanitarian AssistanceClub Representative(Required) First Last Club Representative Position(Required) President Secretary Other Club Representative Phone(Required)Club Representative Email Address(Required) Mailing Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Club Representative SignatureTo sign, click & hold the left mouse button or press & hold your finger inside the dashed box to draw. To clear, click the gray icon in bottom-right corner.
