5.18.22 OUTBoard Agenda Packet - Laserfiche WebLink

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43 ORANGE COUNTY NORTH CAR01JNA 2. Does the applicant's disability require that he or she travel with an attendant? YES NO SOMETIMES Explain: 3. Is there any other medical information we should know in the event of an emergency? (e.g. hepatitis, tuberculosis, cardiac) 4. If the person has a cognitive disability, is he or she able to give name, address, and telephone numbers upon request? YES NO SOMETIMES Explain: Recognize a destination or landmark? YES NO SOMETIMES Explain: 5. If the person is speech impaired, is he or she able to communicate verbally? YES NO SOMETIMES Explain: I verify that the information provided above for verification is true and correct to the best of my knowledge. Signature of Qualified Professional Date