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Wheelchair Ramp Referral
WHEELCHAIR RAMP REFERRAL FORM
Please complete the form below and click submit.
The coordinator of the Wheelchair Ramp Ministry will contact you upon receipt of your form.
If you have any questions, please contact the church office of Front Street UMC at 336.227.6263.
Thank you
*
Required
Errors
Recipient's Name
*
Age
*
Phone Number
*
Address Line 1
*
Address Line 2
City
*
State
*
--
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FL
FM
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MH
MI
MN
MS
MO
MP
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VI
VT
VA
WA
WV
WI
WY
ZIP Code
*
Give directions to the worksite (please use street names, highway #, county road #, north, south, east, west etc.)
*
Describe any medical conditions (Heart, cancer, seizures, COPD, amputee, etc.)
*
Check all characteristics that apply
Hard of hearing
Visually impaired
Uses walker
Feeble
Not ambulatory
Dialysis
Difficulty talking
Other (please describe)
Other medical conditions
Work site action requested
Wheelchair ramp
Steps
Handrails
Other (please describe)
Other work site action requested
Contact Name (if different from recipient)
Contact Phone
Best time to call
Language spoken
*
English
Spanish
Other
Does recipient own home (or is buying the home)?
*
Yes
No
Mobile home
*
Yes
No
Referral From
Phone
Agency
Address
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