PARK RIDGE LIONS CLUB
Individual Request for Scholarship or Grant

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The Park Ridge Lions Foundation will consider requests from Park Ridge residents only, for limited educational scholarships or to fund vision and/or hearing related exams, therapies and corrective products. Please complete the attached application and return to the Park Ridge Lions. Application deadline is December 1 in order to be considered for a grant in the following calendar year.

Priority for funding will be given to students with vision/hearing impairments from the Park Ridge community. Non-students in need of grants for vision and hearing related issues are a second priority. Scholarships for students without disabilities, but who have a declared major in the field of disabilities may also be considered.

Please print out this application and return to:

Park Ridge Lions Club
P.O. Box 200
Park Ridge, Illinois 60068

Name:_______________________________________________________

Address:_______________________________________________________________

City:_______________________________ State:_______________ Zip:____________

Telephone:___________________________ Fax:______________________________

If under age 18, name of parent or guardian:_______________________________________________

Request is for:(check one) ____educational scholarship -------______Hearing/Vision Grant

Description of impairment/need:_____________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

For educational scholarships:

Name of educational institution: _______________________________________________________

School year begins:_________________________
Annual tuition costs:________________________

Yes-No---Applicant has a verifiable hearing or vision impairment
Yes-No---Applicant qualifies for other educational financial support
List any special awards, field of study and other relevant information.

For hearing/vision care grants:

Name of medical practitioner:_______________________________________________________
Estimated costs of medical service/need:____________________________________

Yes-No---Applicant qualifies for medicaid or other government assistance
Yes-No---Applicant does not qualify for medicaid but requires financial assistance

Use additional pages as necessary. Return with other support materials as necessary.

Signature:__________________________________ Date:____________________

Approved grant recipients must agree to terms and conditions set forth by the Park Ridge Lions Club and Foundation.