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New applicant
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Other_3
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Blind Visual Impairment_1
Mental Cognitive Impairment
Dementia
Alzheimer s
Other_2
DHH Deaf orHard of Hearing_1
Speech Impaired
YES
NO
LSS Life Support System Equipment required to sustain their life If checked please write equipment below_2
Wheelchair
Walker Cane
Ventilator
Home Oxygen System
LSS Life Support System
Other Describe_1
Lock Box
Hidden Key Box
Storm Shelter
I amself ambulatory
I am ambulatory but need assistance
I am in a wheelchair and require a vehicle equipped with a lift
NO
I amprone to falls
YES
x

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