Special Olympics Form

Establishment/Provider's Name

Physical Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Is this location close to public transportation?

Phone Number:

Area CodePhone Number

Fax:

Email:

Web Address:

Main Contact Name and Title:

Phone Number:

Email Address:

Services offered at establishment:

Days/Hours of operation:

Languages Spoken:

Other

Fees/Payment Options:

If you accept Medicaid what kind?

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:

Would you be willing to offer any pro bono services?

Intake Procedures (e.g. applications, 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:

Special Olympics Florida Healthy Community Statewide Database Application

Contact Information

Provider Overview

ACKNOWLEDGEMENT