United Way of Wayne and Holmes Counties

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Phone Number

330-263-6363

Address

215 South Walnut Street, Wooster, OH 44691

HOURS

Mon - Fri 8:00am – 4:30pm

Application for Lions Club Assistance — Wooster Noon Lions Club

Applicant Information

Name of Applicant

Age

Parent's Name (if applicant is under 18)

Street Address

City

ZIP Code

Phone Number

Applicant Email Address (used to send you a copy of your application)

School District

How long have you lived at your current address?

How long have you lived in Wayne County?

Previous Address (complete only if less than 3 years at current address)

How long did you live at your previous address?

Medical & Household Information

Do you presently wear glasses?

Yes No

If yes, how old is your current prescription?

Has the Lions Club ever helped you before?

Yes No

If yes, when?

What circumstances should the Lions Club consider (health, employment, or financial situation)?

What type of financial assistance are you requesting? (check one)

Eye Exam

Glasses

Both

Could you afford to pay for any portion of this expense?

Yes No

If yes, how much?

Household Information

List everyone living in your household.

Name	Relationship	Age

Total Household Income (combined monthly income for all household members)

Household Expenses & Employment

Does anyone in your household own real estate?

Yes No

If yes, estimated value

If renting, landlord's name and phone number

Household Expenses

Do not include amounts paid through assistance programs.

Monthly Rent or Mortgage

Subsidized by Metro Housing?

Yes No

Gas

Electric

Phone

Water / Trash

Other Expenses

Employment / Income

Please email proof of income for all household members over 18 to info@uwwh.org.

Name of Person Completing Application

Name of Current Employer

Employer Address & Phone Number

How Long Employed

Hourly Rate of Pay

Hours Worked Per Week

Approximate Take-Home Pay Per Week

If not currently employed, please explain in detail:

Employment History & Certification

Previous Employment History

For the last five years — attach additional sheets if needed.

From (Mo/Yr)	To (Mo/Yr)	Employer Name & Telephone Number	Reason for Leaving

Assistance Programs

Check Yes or No for each program you currently receive.

Program	Currently Receiving?	Amount Per Month

Health Insurance

Please indicate whether you are currently eligible for any of the following.

I certify that all information in this application is complete and true.
I authorize the Lions Club to access records necessary to verify this application.

Signature (type your full name, or parent or guardian if under age 18)

Date

★ Please send proof of income for all household members over 18, along with any other supporting documents, directly to info@uwwh.org ★

Submitting will send your completed application to info@uwwh.org and to the email address you entered above.

Application Ready to Send

Your email program should now be open with your completed Lions Club Assistance Application addressed to info@uwwh.org.

Don't forget: please email proof of income for all household members over 18, along with any other supporting documents, directly to info@uwwh.org.