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Hearing Aid Request

The Westmont Lions and all Lions are known for their hearing aid programs and service projects. As one of our core mission programs, we have worked hard within the community to provide free screenings at local events. To qualify, please fill in the required assistance request form, all information must be submitted to validate qualification requirements. The Westmont Lions will review your request for assistance and work with Lions International Foundation in determining approval, out of pocket and local centers that will be able to provide the needed services. Please understand that this request may take up to 2 months for review and determination as many factors will apply for this request. 

Please download the following pdf document, read, sign and upload back to the request form. These are required for submission and review, if missing, your form will not be processed.

WESTMONT LIONS' HEARING AID ASSISTANCE REQUEST

Please note that all applicants must be 18 to apply.

Birthday
Month
Day
Year
Sex
Are you currently working?
If NO, are you DISABLED?
Student?

If you have insurance, you must go through your insurance prior to requesting assistance from the Westmont Lions.

Do you have Medical Insurance? Check all that apply.
Assistance Requested?

Monthly Income

Monthly Expenses

Please note that this process may take up to 2 weeks to review and process. All income and expenses must be listed; any blank or incomplete lines will not be processed for review.

Please ensure you downloaded the required Hearing Aid Consent Form, complete and upload for review with this submission.

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The above information is true to the best of my knowledge.

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