Request edit access
Enable The Disabled 
Application Form- Please take a moment to fill out this form in its entirety. Any questions should be sent by email to enablethedisabled2021@gmail.com. Remember we need ALL CONTACT information, address and phone number are very important and part of screening. Thank you!  
Sign in to Google to save your progress. Learn more
Email *
Today's date *
MM
/
DD
/
YYYY
Is this person filling out this document the actual person or advocate? *
 Applicants Full legal name AND ADDRESS (your application will not be processed without this information)
Applicant's phone number *
Marital Status *
How many people are in your household? *
Your date of birth *
MM
/
DD
/
YYYY
Are you a current resident of Monroe County, Michigan *
Please describe your permanent physical condition. *
Please explain your exact durable medical need and how it will impact you at home, job site, and community, both physically and socially. What piece of equipment are you requesting? (If requesting bariatric size equipment, it is important to put your weight for ordering purposes) *
Employment Status  *
Annual income of your household (please have last years income tax forms ready upon request) *
Is your permanent physical disability documented by a registered physician?  *
After you submit your application it will be reviewed by our board members. You will be contacted through your email, so please make sure you check. If you are selected, we will set up an appointment to meet you and gain additional information regarding your equipment. We look forward to helping you increase your mobility.  *
Questions, Comments or Concerns
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms