Establishment/Provider's Legal Name:

Common Name (AKA):

Physical Address (including City, State & Zip Code):

Is this location close to public transportation?

Yes No

Mailing Address (if different):

Main/Toll-Free Number:

Fax:

TDD/TTY:

Other:

Website:

E-mail Address:

Provider Type

Office Type:

Please choose the accessibility features available at this location:

Main Contact Name & Title:

Phone Number(s):

E-Mail Address:

Alternate Contact Name & Title:

Phone Number:

E-Mail Address:

Brief description of Establishment:

Specialty:

Service Area:

Days/Hours of Operation:

Fees/Payment Options:

Serves (choose all that apply):

Do you offer discounted prices or a sliding fee for individuals with intellectual or developmental disabilities?

If "Yes", please explain:

Do you have specific days that you would see patients with intellectual or developmental disabilities?

If "Yes", please explain:

Would you be willing to offer any pro bono services on a short term basis?

If "Yes", please explain:

Does your establishment provide staff with sensitivity training?

Are there a maximum number of individuals with intellectual or developmental disabilities that your establishment is willing to see per month?:

If "Yes", how many?

If this practice has other sites, please list the addresses and phone numbers below:

Please include a copy or copies of all associated business cards for our files (i.e. other sites, contact persons, physicians, etc.):

"I attest that the information provided on behalf of our establishment/organization is true and accurate. I also understand and agree that misrepresentation or omission of pertinent information regarding the provider and/or services provided will result in the deletion of the provider or organization from the database without notice. Furthermore, it is acknowledged and understood that participation in the statewide database does not constitute in endorsement of the Provider by the Special Olympics Florida." Please type your name and the date:

** This form must be fully completed and signed before informtion can be entered into our Referral Database. **

Special Olympics Florida Healthy Community Statewide Database Short-Form Application

CONTACT INFORMATION

PROVIDER OVERVIEW

The information below is obtained solely to better match client needs with the appropriate service providers and will not affect your application to enlist in our database as a resources.

ACKNOWLEDGMENT