<p> Meridian District of the United Methodist Church VIM RAMP Work Site Referral Form 2013</p><p>CLIENT NAME: ______AGE:___ PHONE: ______</p><p>STREET ADDRESS (Not Post Office Box): ______</p><p>GIVE DIRECTIONS TO WORK SITE PLEASE USE STREET NAMES, HWY’#S, COUNTY ROAD #’S, NORTH, SOUTH, EAST, WEST, ETC.</p><p>NAME OF NEAREST UNITED METHODIST CHURCH:______</p><p>DESCRIBE ANY MEDICAL CONDITIONS: (HEART, CANCER, SEIZURES, COPD, AMPUTEE, ETC.)</p><p>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</p><p>DAYS CLIENT IS AVAILABLE: </p><p>LANGUAGE SPOKEN: ENGLISH SPANISH OTHER</p><p>DOES CLIENT OWN HOME (OR IS BUYING THE HOME) YES NO</p><p>REFERRAL FROM:______PHONE: ______AGENCY: ADDRESS: </p><p>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______</p>