Disabled or Electricity Dependent Services Application

If you are in immediate danger please contact your local emergency services or dial 9-1-1.

Disabled or Electricity Dependent Services Application
Individuals who complete the application below will be contacted by their local Disability Disaster Access & Resource Center (DDARC) staff and assessed for disaster and emergency services, including Public Safety Power Shutoff (PSPS) events.

Downloadable PDF version (English)

Downloadable PDF version (En Español)

Seleccione el menú desplegable de idioma en la parte superior derecha de la página para traducir el formulario incrustado.

    Contact Info



    Use "noemail@disabilitydisasteraccess.org" if you do not have your own email address.





    Select your phone type

    Your Address











    Resource Questionnaire



    Select a Living Arrangement

    If the power were to go out at your home, do you have any backup source of electricity to use?


    Are you on the Medical Baseline Program?(Links to external application page)

    Do you have a personal or household emergency plan?

    Are you willing to work on and use it?

    Are you receiving or are you eligible for any type of public benefits?






    By submitting this application, you are agreeing to receive periodic marketing emails. Please only click once, the revolving icon means the form is processing.

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