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Financial Assistance for Medical Devices
Volunteer Positions Available
Events Calendar
Our Club
Become a Member
Book the Hall
Forms
Become a Member
Book the Hall
Financial Assistance for Medical Devices
Volunteer Positions Available
Events Calendar
Lanark & District Civitan Club
Financial assistance for medical devices
Apply for assistance with the costs of medical devices or equipment
First Name
*
Last Name
*
Phone Number
Email Address
*
Item being requested
*
Reason For Request:
*
Cost Details
Cost of item:
*
Insurance Coverage:
*
ODSP/ODB Coverage:
*
Money from Other Organizations:
*
Your Contribution:
*
TOTAL REQUEST:
*
Have you requested support from the Lanark Civitan before?
*
Yes
No
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