Meridian District of The

Meridian District of the United Methodist Church VIM RAMP Work Site Referral Form 2013

CLIENT NAME: ______AGE:___ PHONE: ______

STREET ADDRESS (Not Post Office Box): ______

GIVE DIRECTIONS TO WORK SITE PLEASE USE STREET NAMES, HWY’#S, COUNTY ROAD #’S, NORTH, SOUTH, EAST, WEST, ETC.

NAME OF NEAREST UNITED METHODIST CHURCH:______

DESCRIBE ANY MEDICAL CONDITIONS: (HEART, CANCER, SEIZURES, COPD, AMPUTEE, ETC.)

CHECK CHARACTERISTICS THAT APPLY: WORK SITE ACTIONS REQUESTED: HARD OF HEARING WHEELCHAIR RAMP VISUALLY IMPAIRED STEPS USES WALKER HANDRAILS FEEBLE OTHER (PLEASE DESCRIBE) NOT AMBULATORY DIALYSIS DIFFICULTY TALKING

DAYS CLIENT IS AVAILABLE:

LANGUAGE SPOKEN: ENGLISH SPANISH OTHER

DOES CLIENT OWN HOME (OR IS BUYING THE HOME) YES NO

REFERRAL FROM:______PHONE: ______AGENCY: ADDRESS:

Call Jerry Fox @ 601-737-5325/601-917-2284 or Charles Blake @ 601-655-8928/601-480-1937 or complete and email this form to [email protected] or [email protected] Rev. 6/13 Date: Rec’d______House Power Panel: YES/No Scouted______Completed______