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Center for Independent Living Southwest Kansas

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Contact Information
Last Name:
First Name:
Address:
City: State: Zip Code:
Phone:
Demographic and Disability Information
Date of Birth:
Social Security
Number:
Medicaid: Yes No
Medicaid
Number:
Disability
Determination:		 Yes No
Requested
Waiver:
Physically Disabled
Traumatic Brain Injury
Mental Retardation / Developmental Disability
Working Healthy / WORK Waiver
Comments
Center for Independent Living Southwest Kansas | 1802 E. Spruce St. | P.O. Box 2090 | Garden City, KS 67846
toll-free: 800.736.9443 | phone: 620.276.1900 | fax: 620.271.0200 | e-mail: info@cilswks.org
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