DEPARTMENT OF TRANSPORTATION, USCG, CG-5494 (6-88)
DATE:____________
SPONSOR'S NAME:_______________________________ SSN#:________________
RATE:___________ DISTRICT:______________ UNIT:_____________________
WORK NUMBER:____________ HOME ADDRESS:______________________________
(INCLUDE ZIP CODE)
HOME NUMBER:_________________________
NAME OF CHILD/SPOUSE WITH SPECIAL NEEDS:____________________________
DATE OF BIRTH OF CHILD/SPOUSE:______________________________________
TYPE OF DIAGNOSED SPECIAL NEEDS CONDITION (Deaf, Vision or Speech Impaired;
Cerebral Palsy; Mental Retardation; Attention Deficit Disorder; Down Syndrome; Spina Bifida;
Seizure Disorder; Learning Disabilities; Developmental Delays; Emotionally Disturbed;
Hydrocephalus; Chronic illnesses such as heart, kidney, cancer, asthma, blood disorders, tumors;
Depression; Head or Spinal Cord Injuries; etc.):
CAUSE OF SPECIAL NEED (if known):
TYPES OF THERAPY/TREATMENT NEEDED OR CURRENTLY RECEIVING
(Speech; Physical Therapy; Occupational Therapy; Psychotherapy; Chemotherapy; Radiation;
Specific Medications; Medical Specialists; etc.):
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