HANDICAP SANCTUARY
Application Form

(PLEASE PRINT)

NAME _____________________________ Age ___ Sex ___ Phone # ___-____-_____

Marital Status ____ Social Security # ____-___-_____ Drivers License # _______________

Disability ( Please Explain )___________________________________________________
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Are You On A Special Diet _____ (IF YES PLEASE EXPLAIN)_____________________
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Will You Need Any Daily Assistance____ (IF YES PLEASE EXPLAIN) _______________
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Are You Currently Enrolled On :
Social Security Disability _____ Medicare _____Medicaid _____ Other Insurance ______

Nearest Relative ___________________________________Phone # ____ - ____ - ______

In Case of Emergency Contact ________________________ Phone # ____ - ____ - ______

How Many Will Be Living With You ( If Any ) ______
Would You Consider Having A Roommate _______

Please List Any Hobbies or Interests ___________________________________________
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Mail To: HANDICAP SANCTUARY - P.O. Box 690 Point Blank, Texas 77364-0690
©2001 All Rights Reserved to HANDICAP SANCTUARY
DO NOT WRITE BELOW THIS LINE
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