Apply for a Portable Ramp

Name (* required)

Street Address

City (* required)

State (* required)

Zip Code (* required)

County (* required)
—Please choose an option—AdairAllenAndersonBallardBarrenBathBellBooneBourbonBoydBoyleBrackenBreathittBreckinridgeBullittButlerCaldwellCallowayCampbellCarlisleCarrollCarterCaseyChristianClarkClayClintonCrittendenCumberlandDaviessEdmonsonElliottEstillFayetteFlemingFloydFranklinFultonGallatinGarrardGrantGravesGraysonGreenGreenupHancockHardinHarlanHarrisonHartHendersonHenryHickmanHopkinsJacksonJeffersonJessamineJohnsonKentonKnottKnoxLarueLaurelLawrenceLeeLeslieLetcherLewisLincolnLivingstonLoganLyonMcCrackenMcCrearyMcLeanMadisonMagoffinMarionMarshallMartinMasonMeadeMenifeeMercerMetcalfeMonroeMontgomeryMorganMuhlenbergNelsonNicholasOhioOldhamOwenOwsleyPendletonPerryPikePowellPulaskiRobertsonRockcastleRowanRussellScottShelbySimpsonSpencerTaylorToddTriggTrimbleUnionWarrenWashingtonWayneWebsterWhitleyWolfeWoodford

Phone Number (* required)

Email (* required)

Are you a Medicare recipient? (* required)
—Please choose an option—YesNo

Are you a Medicaid recipient? (* required)
—Please choose an option—YesNo

I am a... (* required)
—Please choose an option—Individual with a DisabilityFamily Member, Guardian, Authorized RepresentativeRepresentative of EducationRepresentative of EmploymentRepresentative of Health, Allied Health, RehabilitationRepresentative of Community LivingRepresentative of TechnologyOther

Best estimate of the slope/rise (in inches or number of steps) where the ramp will be installed (* required)

Name of person(s) or group installing the ramp (required)

Include any additional information you would like to provide

I agree to the Terms and Release of Liability