Submitted by linzy.gressett on Fri, 09/27/2024 - 10:06 Participant Contact Information Name Physical Address Mailing Address City State - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Phone Number Alternate Phone Number Email Address Are you requesting equipment on behalf of a minor? Yes No Parent / Guardian Information Required when requesting equipment on behalf of a minor Name Physical Address Mailing Address City State - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Phone Number Alternate Phone Number Email Address Participant Information Date of Birth Gender Male Female Race African-American Asian-American Caucasian Hispanic-American Other Please List Other Race General Disability Type Vision Hearing Speech Learning, Cognitive, Developmental Mobility Other If Other, Please Explain Funding Source Medicaid Medicare Private Insurance Other Please List Other Funding Source How did you hear about Project START? Required Documentation Required Documentation: Applications will not be processed without a copy of Driver’s License, State Issued ID, or Documentation of Disability. (A documentation of disability is defined as a letter from physician, nurse, case worker, other certifying official, or copy of SSI Letter) Upload In order to receive equipment individuals must: Reside in Mississippi Have a documented disability Have no other readily-available funding source Item(s) Requested Computer Refurbished Desktop Refurbished Laptop No Computer Requested For what purpose will you use your computer? Loaner Equipment Wheelchair (Enter additional information below) Cane / Crutch / Walker Communication Device Vision Device Activity of Daily Living Device Other No Loaner Equipment Requested Please List Other Equipment Requested Additional Wheelchair Information Height Weight Level of Injury By signing below, to the best of my knowledge, I verify that all the information in this document is complete and accurate. Recipients' Signature Date CAPTCHA Submit Reset