Special Needs Alert Program SNAP

Enrollment Form 

Date of application: ______________________________________County:________________________

Child’s name: ____________________________________________________________________________ 

Date of Birth: ___________________________________________________________________________ 

Address:__________________________________________________________________________________ 

School:__________________________________________________County:__________________________ 

Child’s primary diagnosis:________________________________________________________________ 

Parent or guardian filling out application:_______________________________________________

Address: _________________________________________________________________________________ 

Home Phone:_____________________________________Work Phone:_______________________________ 

Cell Phone:____________________________e-mail_____________________________________________ 


To begin the enrollment process, mail the SNAP Enrollment Form and your signed Consent Form to:
 
SNAP Coordinator 
Office of EMS, Blue Hen Corporate Center, Suite 4-H 
655 South Bay Road 
Dover, DE 19901

You will be contacted once your forms are received in our office. 

Please feel free to call if you need further information. 
Voice: (302) 744-5400 Fax: (302) 744-5429 

DELAWARE HEALTH AND SOCIAL SERVICES 
Division of Public Health
Office of Emergency Medical Services

Easter Seals

This project was supported in part by grant number 1 H33 MC00112-03 from the Department of Health 
and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. 

Doc. #35-05-20/07/03/25