Special Needs Information Form

Name *

First Name

Last Name

Mailing Address

Your mailing address.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you reside in an apartment or home with a lot number? *

If yes, provide your apartment or house number below.

Yes

No

Home Phone *

(###)

###

####

Mobile Phone

(###)

###

####

Hearing Impaired *

Is your hearing impaired or do you have trouble hearing?

Yes

No

Visually Impaired *

Is your vision impaired or do you have trouble seeing?

Yes

No

Non-Ambulatory *

Yes

No

TTY Machine *

This is a special communications device for hearing or speech impaired.

Yes

No

Transportation Assistance Needed *

If it became necessary to leave your residence, would you need assistance leaving?

Yes

No

Transportation Assistance Vehicle

What type of vehicle would be required for transportation assistance?

Ambulance

Handivan

Is someone completing this survey on your behalf? *

If yes, please fill out the following Emergency Contact information forms.

Yes

No

Emergency Contact

First Name

Last Name

Emergency Contact Phone Number

(###)

###

####