Resident’s Forms

Click on the links below
to access the appropriate form

Disabled Assistance Application

Date of Application*
MM slash DD slash YYYY
Applicant Name*
Phone Number*
Address*
Street Address City State
Please explain what you are in need of:
- Freedom Alert
- Ramp/Lift Gate
- Medical Equipment
Explain
Please check which applies to you:
- I am 65 years of age or older AND live alone.
- I am the primary care giver for a household member who is incapacitated and is unable to take care of his/her self.
- I do not meet the above criteria, but I wish to be considered for this pilot program due to the following conditions:
Reasons why you should be considered for this pilot program, even though you do not meet the first two conditions:
A MEDICAL NOTE FROM YOUR DOCTOR WILL BE NEEDED TO COMPLETE THIS REQUEST.
*
I certify that the above information is true and accurate to the best of my knowledge.