Special Olympics Pennsylvania's (SOPA's) Healthy Athletes Provider Application
Athletes (individuals with intellectual disabilities) might receive referrals for follow-up care from Healthy Athletes screenings, and Special Olympics Pennsylvania is committed to assisting them find the services and resources that they require when they return to their local communities. This is an opportunity for you to become a provider to an under-served, yet very deserving population. Completing this application does not require you to offer free or reduced services or add anything to your normal services. It is simply a way for us to include your contact information within our directory.
ESTABLISHMENT INFORMATION
Establishment Name:
*
Provider's Name(s):
*
Mailing Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
-
Area Code
-
Phone Number
Ext. (if N/A put 0)
Fax:
Website:
Establishment Type (Check All That Apply):
*
Private
Non-Profit
Faith-Based
Government (State)
Government (Federal)
Other
Establishment Type:
*
Please Select
Primary/Main
Satellite
Administration
Please choose the accessibility features available at this Establishment (Check All That Apply):
*
Fully Accessible
Limited Access
No Access
Designated Parking
Full Wheelchair Access
Elevators
Other
Days of Operation (Check All That Apply):
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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Hours of Operation:
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Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: Sunday:
Fees/Payment Options (Check All That Apply):
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Private Pay/Fee for Service
Private Insurance
Medicare
Medicaid
Other
CONTACT INFORMATION
Contact First and Last Name:
*
Contact Title:
*
Phone Number:
*
-
Area Code
-
Phone Number
Ext. (if N/A put 0)
E-mail:
*
The information below is obtained solely to better match Special Olympics Pennsylvania athletes with the appropriate establishments and will not affect your application to enlist.
Serves (Check All That Apply):
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Under 18 Only
18+ Only
Women Only
Men Only
Alzheimer's/Dementia
Individuals with Intellectual Disabilities
Other
Do you offer discounted prices or a sliding fee for individuals with Intellectual Disabilities?
*
Please Select
Yes
No
If "Yes", please explain:
Do you have specific days that you would see individuals with Intellectual Disabilities?
*
Please Select
Yes
No
If "Yes", please explain:
Signature consenting to be listed within Special Olympics Pennsylvania's Healthy Athletes Provider Directory:
*
Submit
Should be Empty: