Mobile Screening Scheduling – Lions District 22W

Club Scheduling

Point of Contact Info

Name

First

Last

Email Address

Lion Title

Treasurer
Secretary
Other

Address

Address Line 1

City

State

Zip Code

Phone Number

Event Name

Number and Driver

Event Date and Time

Date

Time

Event Location

Address Line 1

Address Line 2

City

State

Zip Code

Driver

First

Last

Screenings

Vision
Hearing
Blood Pressure
Blood Sugar*

*District 22-W Diabetes Committee has announced that Lions Clubs cannot provide blood screening unless they have certified medically trained personnel or are coordinating with a medical diabetes group. For more information about qualifications, contact Lion Dianne Walbrecker or Lion Tom Harney.

Usage Fees

Price: $0.00