Bradley Lions ClubBradley, IllinoisDonate

Vision & hearing assistance

A little help. A clearer outlook.

Apply for help with an eye exam, eyeglasses, a hearing test, a hearing aid, or another related need. Bradley Lions will review the submitted information and contact the applicant about next steps.

Before you begin

Have your household details ready.

This application asks for contact, household, work, income, expense, insurance, and Medicaid information from the club’s current paper application. If the applicant is under 18, a parent or guardian must complete the rest of the application.

Download the original application (PDF)
01

Applicant information

Tell us who is requesting assistance and how to reach them.

Sex

Provide at least one telephone number.

02

Assistance requested

Select every service that applies.

Assistance requested
A parent or guardian must complete the rest of this application for an applicant under 18.
03

Household & work

Complete the fields that apply to your situation.

Working
Disabled
Student
Student status
04

Monthly income & expenses

Enter monthly amounts in dollars.

Total monthly income
$
$
$
$
$
$
Total monthly expense
$
$
$
$
$
$
05

Coverage

Tell us about any available medical coverage.

Medical insurance
Medicaid card
06

Applicant signature

The adult requesting assistance must type their full legal name.

Your signature preview

This application is emailed directly to Bradley Lions. It is not stored in a website database.