Lions Serving Humanity Program

Emergency Assistance
Non-Emergency Assistance
Completed Projects

Non-emergency request for services or materials/supplies for a Lions project/mission.

If you are in need of non-emergency services, materials or supplies, then please fill out the form below. Your request will be entered into the Lions Clubs International database. Please read carefully the "Waiver of Liability" at the end of the form.

*Required

*My First Name:

*My Last Name:

My Phone Number:

(Phone numbers will not appear on the Lions Web site. This is a secure site.
Only Lions Headquarters staff will receive phone numbers.)

*My E-mail:

My Lions club:

My District Number:

*My Language Preference:

My Second Language:

*Project Start Date:

Project End Date:

Project State:

Project City:

*Project Geographical Area:

*Project Country:

1. Describe the community to receive assistance.

2. *Describe your project, expected results, and the number of people who will benefit.

3. Is this a cooperative effort with other organizations? If so, please submit the name(s) of the organization(s).

I am requesting the following assistance for my project:

Health care professionals such as doctors, nurses, paramedics, etc.

Allied health professionals

Social workers

Law enforcement officers

Firefighters

Professional relief aid workers

Scientists such as geologists, others

Architects

Engineers such as civil, electrical, others

Heavy equipment operators

Chainsaw operators

Contractors

Carpenters

Construction workers

Electricians

Plumbers

Masons

Landscapers

Small Equipment Operators

Laborers

Truck drivers

Cable communications installers

Cooks and food servers

Other

I am requesting the following materials/supplies for my project:

Medical equipment (surgical equipment, x-ray machines)

Medical supplies (usable supplies such as bandages, plasma)

Survival supplies (potable water, food, tents, blankets, clothing)

Construction supplies

Electrical supplies

Vehicles - trucks or automobiles

Cellular telephones

Computers

Office equipment

Cooking supplies and food

Furniture

Appliances

Bedding

Household items

Other

Additional project details.

Waiver of liability

The undersigned Project Sponsor agrees and understands that participation in the Lions Emergency/Non-Emergency Assistance Database is voluntary. As such, the Project Sponsor his/her heir, personal representatives or assigns, hereby release, waive, discharge and covenant not to sue the International Association of Lions Clubs and Lions Clubs International Foundation, their officers, trustees, employees and agents from liability from any claims including the negligence of the International Association of Lions Clubs, its chartered Lions Clubs, Lions Clubs International, their officers, members, employees and agents, resulting in personal injury, accidents, or illnesses (including death) and property loss arising from, but not limited to, participating in the Lions Emergency/Non-Emergency Assistance Database.

The undersigned project sponsor also agrees to INDEMNIFY and HOLD the International Association of Lions Clubs and Lions Clubs International Foundation HARMLESS from any and all claims, action, lawsuits, procedures, costs, expenses, damages and liabilities, including attorney's fees brought as a result of Project Sponsor's involvement in the Lions Emergency/Non-Emergency Assistance Database.

Agreement

I understand that the president of my Lions club of , in the project country, will be contacted to certify that all funds and materials that the club receives in support of this project will be properly applied to the project and will be promptly acknowledged. This club will send regular reports to the club or district providing assistance and to Lions Clubs International.