Contact Info Your Name (required) Your Email (required) Use "noemail@disabilitydisasteraccess.org" if you do not have your own email address. Contact Number (required) Select your phone type Cell phoneLandline Your Address Mailing Address City County State Zip Code Select if you have a different residential and mailing address. Physical Address City County State Zip Code Resource Questionnaire What type of electric assistive technology or durable medical equipment do you use? How many hours a day do you use each of the devices you listed above? Select a Living Arrangement I live by myselfOthers live with me If the power were to go out at your home, do you have any backup source of electricity to use? I have no backup power sourceYes, I have a backup power source What type of backup electricity? Are you on the Medical Baseline Program?(Links to external application page) I am not on the Medical Baseline ProgramYes, I am on the Medical Baseline Program Do you have a personal or household emergency plan? I have no emergency planYes, I have an emergency plan Are you willing to work on and use it? I am not willing to work on or use an emergency planYes, I am willing to work on and use an emergency plan Are you receiving or are you eligible for any type of public benefits? I do not receive/am not eligible for public benefitsYes, I receive/am eligible for public benefits Do you pay your utility bills, or are they included in your rent payment? YesNoNot Sure Who is your electricity provider? What is your electricity account number? What time of day can we call you to discuss your disaster/emergency/PSPS needs? How did you hear about the DDAR program? (Required) By submitting this application, you are agreeing to receive periodic marketing emails. Please only click once, the revolving icon means the form is processing. Skip back to main navigation
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