Referral Database Application

Special Olympics Florida Healthy Athletes Statewide Database Short-Form Application

If not applicable, please mark N/A where available
Establishment Name:
Provider's Name(s):
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mailing Address (if different):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Is this location close to public transportation?
Phone Number

Area CodePhone Number
Fax:
TDD/TTY:
Other:
Website:
E-mail
Provider Type (Check all that apply)

Other
Office Type:
Please choose the accessibility features available at this location:

Other
CONTACT INFORMATION
Main Contact Name & Title:
Phone Number

Area CodePhone Number
E-mail
Alternate Contact Name & Title:
Phone Number

Area CodePhone Number
E-mail
PROVIDER OVERVIEW
Brief description of Establishment:
Specialty:
Service Area (County):
Service Area (City):
Days of Operation (Check all that apply)
Hours of Operation:
Fees/Payment Options:

Other
The information below is obtained solely to better match client needs with the appropriate service providers and will not affect your application to enlist in our database as a resources.
Would you like to be added to our Follow Up Resources Page on our Website?
Serves (choose all that apply):

Other
Do you offer discounted prices or a sliding fee for individuals with Intellectual or Developmental Disabilities?
If "Yes", please explain:
Do you have specific days that you would see patients with Intellectual or Developmental Disabilities?
If "Yes", please explain:
ACKNOWLEDGMENT

"I attest that the information provided on behalf of our establishment/organization is true and accurate. I also understand and agree that misrepresentation or omission of pertinent information regarding the provider and/or services provided will result in the deletion of the provider or organization from the database without notice. Furthermore, it is acknowledged and understood that participation in the statewide database does not constitute in endorsement of the Provider by the Special Olympics Florida." Please type your name and the date:
Do you agree to these terms and conditions?
Signature
This form must be fully completed and signed before informtion can be entered into our Internal Referral Database.
Should be Empty:

Special Olympics Florida Healthy Athletes Statewide Database Short-Form Application

CONTACT INFORMATION

PROVIDER OVERVIEW

The information below is obtained solely to better match client needs with the appropriate service providers and will not affect your application to enlist in our database as a resources.

ACKNOWLEDGMENT