Test Application

    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.