Surveypoint

Q1

Establishment/Provider's Name

Q2

Physical Address:

Street Address

Q3

Physical Address:

Street Address Line 2

Q4

Physical Address:

City

Q5

Physical Address:

State / Province

Q6

Physical Address:

Postal / Zip Code

Q7

Physical Address:

Country

Q8

Is this location close to public transportation?

Q9

Phone Number:

Phone Number

Q10

Fax:

Q11

Email:

Q12

Web Address:

Q13

Main Contact Name and Title:

Q14

Phone Number:

Q15

Email Address:

Q16

Services offered at establishment:

Q17

Days/Hours of operation:

Q18

Languages Spoken:

Q19

Fees/Payment Options:

Q20

If you accept Medicaid what kind?

Q21

Serves (Choose all that apply):

Q22

Do you offer discounted prices or a sliding fee for individuals with intellectual or developmental disabilities?

Q23

If "Yes", please explain:

Q24

Would you be willing to offer any pro bono services?

Q25

Intake Procedures (e.g. applications, etc.):

Q26

"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:

Olympics Database -Form Fill

Establishment/Provider's Name

Physical Address:

Physical Address:

Physical Address:

Physical Address:

Physical Address:

Physical Address:

Is this location close to public transportation?

Phone Number:

Fax:

Email:

Web Address:

Main Contact Name and Title:

Phone Number:

Email Address:

Services offered at establishment:

Days/Hours of operation:

Languages Spoken:

Fees/Payment Options:

If you accept Medicaid what kind?

Serves (Choose all that apply):

Do you offer discounted prices or a sliding fee for individuals with intellectual or developmental disabilities?

If "Yes", please explain:

Would you be willing to offer any pro bono services?

Intake Procedures (e.g. applications, etc.):