Form
Join our Contact List
Your Name (First and Last)
*
First Name
Last Name
County where you or your loved one resides. (Refers to person who qualifies or may qualify for Pre-enrollment or services through the APD Medwaiver).
*
Baker
Clay
Duval
Nassau
St. Johns
Area 12 Flagler & Volusia
Area 3 Madison, Taylor, Alachua, Bradford, Columbia, Dixie, Gilchrist, Hamilton, Lafayette, Levy, Putnam, Suwannee, and Union
Other
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Secondary Email
example@example.com
Your role
*
Self Advocate (person eligible for, enrolled, and/or receiving services from APD or the APD med waiver pre-enrollment list) )
Family Member - Parent
Family Member - Grandparent
Family Member - Sibling
Professional/Service Provider
Caregiver
Community Leader
Other
Questions, Comments, Request to be contacted?
Submit
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