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.

Note: We are currently experiencing a high level of engagement in this program. We will be responding to applications in the order they are received. Due to the high level of interest, processing may take up to 3 weeks. We appreciate your patience.

Downloadable PDF version (English)*Updated Oct 2022

Downloadable PDF version (En Español)*Actualizado Oct 2022

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.