Front Street United Methodist Church: Home: Wheelchair Ramp Referral

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 *

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

Mobile home *

Yes

Referral From

Phone

Agency

Address

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